Accuracy of portable chest radiography in the critical care setting. Diagnosis of pneumonia based on quantitative cultures obtained from protected brush catheter.

Sixty-six supine portable chest radiographs done on the day of bronchoscopy in 62 critical care unit patients suspected of having pneumonia were examined in a blinded fashion by two radiologists. Quantitative culture results obtained from protected brush catheter (PBC) specimens were compared with chest radiograph scores. For one observer, the sensitivity of the chest radiograph for predicting the presence of positive culture results was 0.60, specificity was 0.29, overall agreement was 0.41, positive predictive value was 0.34, and negative predictive value was 0.55. For the second observer, the values were as follows: sensitivity, 0.64; specificity, 0.27; overall agreement, 0.41; positive predictive value, 0.35; and negative predictive value, 0.55. The kappa statistic was calculated at 0.27 indicating marginal interobserver reproducibility. We conclude the portable chest radiograph in the critical care setting is not accurate in predicting the presence of pneumonia when the diagnosis is based on quantitative cultures obtained from protected brush catheter specimens.

Interobserver variation in the computed tomographic evaluation of mediastinal lymph node size in patients with potentially resectable lung cancer. Canadian Lung Oncology Group.

OBJECTIVE: To measure the reliability of the assessment of mediastinal lymph node size in computed tomographic (CT) scans of the thorax. DESIGN: Observer agreement study in which radiologists, blinded to one anothers' interpretation, were randomized to read 30 scans each. POPULATION: Sixty scans from patients with apparently operable non-small cell carcinoma of the lung were read by radiologists responsible for clinical interpretation (clinical radiologists) and four radiologists with a special interest in thoracic CT (study radiologists). MEASUREMENTS: Radiologists measured the size of left and right superior mediastinal nodes, aortic nodes, and the subcarinal nodes and, on the basis of whether any nodes accessible to mediastinoscopy were greater than 1 cm, recommended whether mediastinoscopy be undertaken. Agreement was quantified using kappa, a measure of chance-corrected agreement. RESULTS: Among all radiologists, agreement on whether there were any nodes larger than 1 cm for right superior mediastinal nodes was 0.68; for left superior mediastinal nodes it was 0.28; for aortic pulmonary nodes it was 0.62; for subcarinal nodes it was 0.58; and for any node greater than 1 cm and accessible to mediastinoscopy it was 0.61. The agreement was very similar when the analysis was restricted to the study radiologists. CONCLUSION: Although the good level of overall agreement suggests that CT provides useful information in the evaluation of mediastinal lymph node size, the disagreement was sufficient that it likely contributes to suboptimal sensitivity and specificity of CT in detecting tumor spread reported in previous studies.

Clinical studies of measuring extravascular lung water by the thermal dye technique in critically ill patients.

We measured extravascular lung water (EVLW) by the thermal-dye technique in a broad group of critically ill patients who had either acute cardiac or noncardiac illnesses. A portable AP supine chest roentgenogram, reviewed blindly, was used to classify patients as to the presence or absence of pulmonary edema; by clinical history we categorized patients into either a cardiac or noncardiac (ie, ARDS) group. With a normal chest roentgenogram, the mean EVLW was 5.6 +/- 1.8 ml/kg, and the pulmonary capillary wedge pressure (PCWP) was 11.3 +/- 5.3 mm Hg (mean +/- SD). In contrast, patients with pulmonary edema on a cardiac basis had a mean EVLW of 10.2 +/- 3.1 ml/kg (mean PCWP, 20.5 +/- 8.2 mm Hg), while patients with clinically defined noncardiac pulmonary edema and a normal PCWP (11.6 +/- 5.7 mm Hg) had a mean EVLW of 15.8 +/- 4.6 ml/kg, significantly higher than in the cardiac group (p less than 0.001). On a severity system of 014, the EVLW increased in parallel to the severity of the chest radiologic appearance of edema in both the cardiac (r2 = .44; p less than 0.001) and noncardiac (r2 = .59; p less than 0.001) patients. This study defined a normal range of thermal-dye EVLW in critically ill patients without radiologic evidence of pulmonary edema. We further demonstrated the increased pulmonary microvascular permeability of noncardiac pulmonary edema compared with cardiac edema by the greater EVLW at normal microvascular hydrostatic pressures in the former group.

The short-term effects of increasing plasma colloid osmotic pressure in patients with noncardiac pulmonary edema.

We infused hyperoncotic albumin (25 or 50 gm of a 50% solution) into patients with noncardiac pulmonary edema (adult respiratory distress syndrome [ARDS]) to evaluate its effect on the transmicrovascular flux from blood to pulmonary edema fluid of two radiotracers--111In-DTPA (mol wt 504) and 125I-human serum albumin (HSA) (mol wt 69,000). Two groups of patients were studied--one with a modest increase in permeability of the pulmonary alveolocapillary membrane to 125I-HSA (group 1) and another with a large increase in permeability to 125I-HSA (group 2). We used furosemide, when necessary, to minimize the effect of albumin infusion to increase the pulmonary microvascular hydrostatic pressure (Pmv), measured clinically as the pulmonary capillary wedge pressure (PCWP). Therapy significantly increased the mean colloid osmotic pressure (COP) in both groups, but not the mean PCWP or calculated Pmv. Albumin had no significant effect on the mean pulmonary transmicrovascular flux of the radiotracers in either group, despite the increase in COP. In individual patients, a change in the Pmv in response to albumin infusion was directly correlated with the change in flux of 111In-DTPA [group 1: delta In-DTPA (%) = 8.66 + 1.4 delta Pmv (%) r = 0.51, P less than 0.02; group 2: delta In-DTPA (%) = -3.43 + 1.6 delta Pmv (%) r = 0.67, P less than 0.01]. A change in the transmicrovascular flux of I-HSA also correlated with a change in the intravascular Starling forces in both groups. We conclude that albumin infusion in patients with ARDS will not augment the pulmonary transmicrovascular flux of low or high molecular-weight solutes when the effect of albumin to increase the Pmv is minimized; nor, however, does an increase in plasma COP significantly reduce the flux of such solutes.

Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft.

Although use of the internal thoracic artery (ITA) for coronary artery bypass grafting results in superior graft patency and improved patient survival, our initial clinical observations suggested an increased incidence of pleuropulmonary morbidity with its use. One hundred consecutive patients with left ITA grafts were studied prospectively and compared with a consecutive retrospective group of 100 patients undergoing coronary artery bypass grafting with saphenous vein grafts only. Preoperative, postoperative day (POD) 2, POD 6, and postoperative week 8 chest roentgenograms were analyzed for atelectasis and effusion. Postoperative left lower lobe atelectasis was common in both groups on both POD 2 (saphenous vein, 43%, versus ITA, 53%; not significant) and POD 6 (saphenous vein, 40%, versus ITA, 41%; not significant). There was a significantly higher incidence of pleural effusion on POD 6 in the ITA group (84% versus 47%; p less than 0.05) but most of these were small. There was more chest tube drainage (1,413 versus 1,028 mL; p less than 0.01) and a greater need for secondary thoracostomy or thoracentesis (4% versus 0%) in the ITA group. The left pleural space was opened in 67 of the 100 ITA patients but pleurotomy did not appear to influence postoperative morbidity. We conclude that use of the internal thoracic artery for coronary artery bypass grafting results in a small but significant increase in pleuropulmonary morbidity.

Giant-cell carcinoma of the lung. A cytologic study.

A case of giant-cell carcinoma of the lung, confirmed at autopsy, is presented. The cytologic features seen in sputum samples, bronchial washings and brushings and fine needle aspiration biopsy material as well as the histologic findings are described. The possible relationship to bronchioloalveolar carcinoma is discussed. The cytologic features of giant-cell carcinoma of the lung, when seen in the context of the clinical and radiologic setting, should allow the cytologic identification of the tumor prior to surgical intervention.

Chronic eosinophilic pneumonia. Diagnosis by fine needle aspiration.

A case of chronic eosinophilic pneumonia in which the diagnosis was established by fine needle aspiration of the pulmonary lesions is presented. The cytologic findings included the presence of an inflammatory exudate consisting of 40% eosinophils, 25% neutrophils and the remaining cells comprised of lymphocytes, histiocytes, atypical columnar cells and cells probably of pneumocyte type II origin. Fine needle aspiration of pulmonary infiltrates can be quite helpful in confirming the diagnosis of chronic eosinophilic pneumonia and in differentiating it from other similar conditions including malignant lymphomas, if the clinical and radiologic appearances are also taken into consideration.

Possible spread of bronchogenic carcinoma to the chest wall after a transthoracic fine needle aspiration biopsy. A case report.

Spread of tumor along the needle tract following aspiration biopsy with the so-called "fine" needles (thinner than 18 gauge) is recognized to be an extremely uncommon complication of this technique. A case is presented in which such a spread appears to have occurred to the chest wall 13 months after a transthoracic aspiration biopsy of a bronchogenic tumor.

Choriocarcinoma metastatic to the lung. A cytologic study with identification of human choriogonadotropin with an immunoperoxidase technique.

A case of choriocarcinoma metastatic to the lung following a previous hydatidiform mole is presented. It was possible to make definitive identification of trophoblastic elements on a needle aspiration biopsy using an immunoperoxidase staining technique, thus avoiding diagnostic thoracotomy prior to therapeutic intervention. A method of immunoperoxidase staining of previously fixed and Papanicolaou-stained needle aspiration biopsy specimens is also described, and other uses of the immunoperoxidase technique on needle biopsy specimens are discussed.

Workload and sources of remuneration for radiologists at a tertiary-care teaching hospital in Ontario.

Detailed information about workload and sources of remuneration for radiologists at a large tertiary-care teaching hospital was reviewed for the calendar year 1991 as part of an assessment of medical professional resources. Radiologists at this facility worked an average of about 50 hours per week. When the intensity of the cases was taken into consideration, there was only a small variation among individual radiologists in terms of workload and income earned for the group. Ninety-three percent of the radiologists' remuneration came as payment for clinical patient care. The radiologists were poorly remunerated for the time they spent teaching, conducting research and performing administrative duties, but this low level of remuneration was partially compensated by the activity of senior residents, who did some work without supervision.

Direct magnification radiography of the chest in diffuse pulmonary disease.

The technique of direct magnification radiography of the lung in diffuse lung disease is very simple to perform. It is probably of value in selected cases where there is clinical suspicion of diffuse lung disease and when the plain radiograph is either normal or inconclusive. It is speculated that the air bronchiologram pattern seen on these radiographs is due to peribronchiolar parenchymal lung disease involving the parenchymal or acinar interstitial space with focal intra-alveolar involvement. An attempt to correlate these morphologic patterns with various pulmonary diseases is also stressed.

Computed tomography to assess pulmonary injury associated with concurrent chemo-radiotherapy for inoperable non-small cell lung cancer.

OBJECTIVE: To characterize serial computed tomography (CT) findings of pulmonary injury after a uniform regimen of concurrent chemo-radiotherapy in inoperable non-small cell lung cancer, and to compare the radiation-induced lung toxicity with other concurrent chemo-radiation regimens. METHODS: Twenty-four patients with advanced non-small cell lung cancer received 2 induction cycles of cisplatin and vinblastine, followed by 2 further cycles of cisplatin and vinblastine, concurrent with 60 Gy radiation at 2 Gy per fraction. Radiation-induced lung injury in the acute and chronic phases was assessed by serial CT scans and compared with preradiation baseline scans. Acute radiation pneumonitis was evaluated using the Common Toxicity Criteria, and chronic radiation fibrosis was graded according to the European Organisation for Research and Treatment of Cancer--Radiation Therapy Oncology Group Scale. RESULTS: Seventeen (81%) patients had characteristic CT findings of radiation-induced pulmonary damage, which were confined to the radiation ports. Although patchy nonhomogeneous and air-space opacities characterized acute radiation pneumonitis, and homogeneous opacities with loss of volume were typical for chronic fibrosis, ground-glass opacities were found frequently in both phases. Acute radiation pneumonitis grade 1 was seen in 29% and grade 2 in 9.5%. Chronic radiation fibrosis grades 1, 2 and 3 were found in 14%, 33% and 19% of the patients respectively. Median survival time was 13 months. CONCLUSION: CT enables detailed evaluation of radiation-induced pulmonary injury after concurrent chemo-radiation for inoperable non-small cell lung cancer. Although survival time with the present regimen is comparable to other concurrent chemo-radiation regimens, a high incidence of radiation injury was found, though the severity was not life threatening.

Pulmonary edema in patients with sepsis.

Fifteen critically ill patients with sepsis, 12 of whom had significant pulmonary dysfunction develop, were investigated with regard to changes in pulmonary capillary pressure, in serum oncotic pressure and on roentgenograms of the chest. It could not be shown that the pulmonary edema, which is a major characteristic of the septic lung lesion, was due to changes only in oncotic and hydrostatic pressures. Nor was there evidence that increased capillary permeability was the sole explanation of the edema. A significant relationship was found which consisted of increasing severity of the lung lesion, decreasing serum oncotic pressure and increasing pulmonary pressure. When patients with sepsis require resuscitation with fluids, the administration of moderate amounts of albumin along with monitoring of pulmonary capillary pressure appears to be a rational approach to therapy.

Anthropometric and computed tomographic assessment of the thigh in young and old men.

Anthropometric (AP) and computed tomographic (CT) methods of determining limb and muscle-plus-bone cross-sectional area (CSA) and volume (Vol) were compared in 13 young (M = 24.5 yrs) and 11 old (M = 71.0 yrs) men. CSA of total thigh, muscle-plus-bone, quadriceps, and hamstring muscle compartments and muscle were measured from CT scans. Corresponding muscle Vol were estimated from anthropometric equations. Prediction equations for CT measures were developed from AP measures using multiple linear regression. AP and CT techniques produced different values for thigh component CSA and Vol, especially in the old men. AP overestimated muscle-plus-bone CSA and Vol (4-6%) and underestimated skin and subcutaneous tissue CSA and Vol (17-33%). Prediction equations for quadriceps CSA and Vol (R2 = 80-96%) were more accurate than equations for hamstrings (R2 = 42-65%). Specific thigh muscle CSA and Vol can be predicted from AP measures (SEE 5-15%). These findings may have clinical significance when normalizing strength per unit of muscle size.

Fine-needle aspiration of bone lesions.

Percutaneous needle biopsy of bone lesions has been done for over 50 years. Although initially not widely used, it has been increasingly accepted over the past several years. Large-bore needles were used at first. However, as cytopathological techniques have improved, fine-needle biopsy has become feasible, offering the advantage of reduced tissue trauma and increased flexibility in needle positioning. We have retrospectively reviewed our fine-needle bone biopsies performed from January 1985 to May 1988 in 53 patients. Repeat aspirations were required on only five patients. Adequate samples were obtained at initial biopsy in the remainder. Accuracy was 0.94 which is comparable with, or better than, reported results obtained using larger bone needles. Accuracy was not affected by site or number of lesions, nor was it markedly different in patients with and without known primary malignant lesions. Biopsy of bone lesions using a fine needle provides a flexible, accurate, and relatively atraumatic alternative to more invasive methods.

Arm and leg composition determined by computed tomography in young and elderly men.

Five computed tomography (CT) scans were taken at measured intervals of the legs and arms of young (n = 7) and elderly (n = 13) men. Cross-sectional areas (CSA) of the total limb, muscle plus bone and bone were measured in each scan, and skin plus subcutaneous tissue areas were calculated by subtraction. In addition, in the arm scans the CSA of the extensor and flexor compartments were measured, and in the leg the CSA of the plantar flexor compartment. A value for lean muscle within these compartments was calculated by excluding non-muscle tissue using density measurements based on Hounsfield units. Related volumes for the various components were also calculated using geometric formulae. The results showed that elderly limbs were of a similar overall size as the young, but elderly muscles were smaller (28-36%) with greater amounts of non-muscle tissue located within a muscle, particularly in the plantar flexors (81% more than in the young). Elderly arms had a greater amount of skin plus subcutaneous tissue than the young, but there was no difference in the legs. Muscle volumes were similar to in vitro results reported from cadaver studies and can be predicted from single mid-limb CT scans using regression equations. These results illustrate that, due to the substantially reduced amount of 'pure' muscle tissue in the elderly, comparisons of relative strength with other populations may be misleading unless appropriate measurements of muscle size are considered. Methods to estimate in vivo physiological CSA, which is considered the best means of normalizing strength, have been demonstrated in this study.

A comparison of anthropometry with computed tomography in limbs of young and aged men.

Arm and leg composition determined by anthropometry (AP, girths, and skinfolds) were compared with computed tomography (CT) in 7 young (mean age 31.4y) and 13 old (74.8y) males. Five transverse CT scans, girths, and skinfold measurements were made. In each CT image, total cross-sectional area (CSA), bone CSA, muscle compartment CSA, and "pure" muscle CSA within the compartment were measured. Corresponding volumes were also calculated. Total limb and muscle plus bone CSA and volumes were estimated from AP measures. The two methods were compared, and multiple regression analyses were used to predict component CSA and volumes from AP measures. In both groups, AP component measures in the leg provided more accurate values than in the arm. Skin plus subcutaneous tissue in the old was not well estimated by AP. The greater preponderance of nonmuscle tissue in the muscle compartments of the old, as determined from CT images, was not related to any AP estimates. Prediction equations for various component areas and volumes were derived. Some equations derived for the young could not be obtained for the old due to the reduced ability of AP to accurately assess limb composition of aged men.

Pulmonary permeability edema in a large animal model of nonpulmonary sepsis. A morphologic study.

Morphologic studies were undertaken in a sheep model of pulmonary permeability edema (PPE) induced by cecal ligation and perforation. Biopsies taken every 24 hours through 96 hours following induction of sepsis showed, at 24 hours, interstitial edema accompanied by widespread aggregation of polymorphonuclear leukocytes. This was confirmed by electron microscopy, which also demonstrated endothelial cell swelling, platelet aggregation, and fibrin deposition. By 48 hours, a "thromboangiitis" had developed that persisted through 96 hours. In vitro pulmonary angiograms done at 60 and 96 hours showed multiple filling defects; it was possible to demonstrate that these defects corresponded to the "thromboangiitis." These thrombotic lesions, which were not the result of embolization from indwelling lines, closely resembled vascular changes described in the adult respiratory distress syndrome. It is believed that this is the first time that such lesions have been described in a model of PPE resulting from nonpulmonary sepsis.

Hypersensitivity pneumonitis: evaluation with CT.

Thirteen chest radiographs and computed tomographic (CT) scans obtained from 11 patients with hypersensitivity pneumonitis were reviewed. The CT findings were correlated with open lung biopsy findings in seven patients. The two patients with acute hypersensitivity pneumonitis showed air-space opacification on CT scans. An open lung biopsy, done in one of these patients, demonstrated noncaseating granulomas and filling of the air spaces with macrophages. The nine patients with subacute hypersensitivity pneumonitis showed small, rounded opacities and patchy air-space opacification on CT scans. These findings reflected the histologic findings, which consisted of interstitial pneumonitis, cellular bronchiolitis, and small, noncaseating granulomas. The six patients with symptoms for 12 months or longer also showed irregular linear opacities on CT scans, corresponding to areas of fibrosis. CT scans were superior to radiographs in helping to assess the type and extent of abnormalities, and high-resolution CT scans were superior to conventional CT scans.

Thigh composition in young and elderly men determined by computed tomography.

Computed tomography (CT) was used to quantify components of the thigh in young (n = 13) and elderly (n = 11) men. Cross-sectional areas (CSA) of the total limb, total muscle plus bone, quadriceps compartment, hamstring compartment and bone were measured at each of five scan sites along the length of the thigh. Non-muscle tissue (NMT) areas within the muscle compartments were measured using changes in density based on Hounsfield units. Skin plus subcutaneous fat areas and quadriceps and hamstring lean muscle areas were calculated by subtraction. Geometric formulae were used to calculate related volumes for each thigh component. Volumes were also predicted from regression equations employing thigh length and component CSA from single mid-limb CT scans. The results showed that while total thigh CSA was not different in elderly men, they had significantly smaller total muscle plus bone (13.0%), and quadriceps (26.4%), and hamstring (17.9%) muscle areas. The elderly men also had significantly greater CSA for skin plus subcutaneous fat (37.6%), and for NMT in the quadriceps (59.4%) and hamstring (127.3%) muscle compartments. These results suggest that comparisons of relative leg muscle strength between young and elderly men may be misleading due to the decrease in actual muscle tissue associated with ageing. Appropriate quantification of muscle size and CSA must be carried out before such comparisons can be meaningful.