Validity of lung ultrasound to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure.

INTRODUCTION: Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of lung ultrasound, conducted by pulmonologists without experience in this procedure, to tule out pneumothorax after invasive procedures. MATERIAL AND METHODS: Our prospective observational study consecutively included patients who underwent transbronchial lung biopsy (TBLB), therapeutic thoracentesis (TT) and/or transparietal pleural biopsies (PB) for whom subsequent chest radiography to rule out complications was indicated. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered in the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the "barcode" sign. RESULTS: We included 275 procedures (149 TBLBs, 36 BPs, 90 TTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. CONCLUSIONS: Lung ultrasound performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.

Small-cell lung cancer in never-smokers.

BACKGROUND: Lung cancer is a public health problem worldwide. Small-cell lung cancer (SCLC) is the most aggressive histologic type, with a 5-year survival <10%. SCLC is closely associated with tobacco consumption and infrequent in never-smokers. We aim to describe SCLC characteristics in never-smokers recruited in a radon-prone area. PATIENTS AND METHODS: We designed a multicentric case series where SCLC cases were recruited consecutively following histologic confirmation. Detailed information was obtained for indoor radon exposure, occupation and environmental tobacco smoke. We also collected different clinical characteristics such as extended or limited disease at diagnosis. RESULTS: We recruited 32 never-smoking SCLC cases. Median age was 75 years and 87.5% were women; 47% had extended disease. Median radon concentration was 182 Bq/m3. There were no statistically significant differences in residential radon concentration neither regarding age at diagnosis nor regarding sex. The most frequent symptoms were constitutional syndrome (23.1%) and coughing (23.1%). As much as 63% of cases had an Eastern Cooperative Oncology Group Study (ECOG) status of 0-2. The 1- and 2-year survival rates were 34.4% and 21.9%, respectively. The 2-year survival rate with a localized tumor was 26.7%, compared with 18.8% for extended disease. CONCLUSIONS: These results show, for the first time, that indoor radon might not be associated with SCLC characteristics at diagnosis in never-smokers, and also confirms the low survival of this aggressive type of lung cancer also for never-smokers.

Validity of thoracic ultrasonography to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure. / Validez de la ecografía torácica para descartar neumotórax iatrogénico realizada por neumólogos sin experiencia en este procedimiento.

INTRODUCTION: Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of thoracic ultrasonography to rule out pneumothorax after invasive procedures, conducted by pulmonologists without experience in this procedure. MATERIAL AND METHODS: Our observational prospective study consecutively included patients who underwent transbronchial biopsy (TBB), evacuating thoracentesis (ECT) and/or transparietal pleural biopsies (TPB) who were indicated subsequent chest radiography to rule out complications. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the «barcode¼ sign. RESULTS: We included 275 procedures (149 TBBs, 36 TPBs, 90 ECTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and a positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. CONCLUSIONS: Thoracic ultrasonography performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.

Social and clinical predictors associated with prolonged hospital stays for patients with severe exacerbation of chronic obstructive pulmonary disease. / Predictores sociales y clínicos asociados con estancia hospitalaria prolongada en pacientes con agudización grave de EPOC.

OBJECTIVE: To determine whether there are social factors that affect the prolonged hospital stay (PHS) of patients with severe chronic obstructive pulmonary disease exacerbation (COPDE), as well as clinical-demographic factors. METHODOLOGY: We conducted a prospective cohort study that consecutively included patients who were admitted to a Pneumology department for COPDE. We recorded demographic, clinical (tobacco use, exacerbations and infections, dyspnoea, impact according to CAT questionnaire, pulmonary function, comorbidities, oxygen therapy and noninvasive ventilation) and social (financial status, caregiver availability and overload, dependence for basic and instrumental activities, social risk and use of social services) variables, employing questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber and Gijón. We performed a univariate and multivariate analysis using a logistic regression model. RESULTS: The study included 253 patients, with a mean age of 68.9±9.8years; 77.1% of whom were men. The logistic regression model included active tobacco use, FEV1 value, CAT score >10, dyspnoea 3-4 on the MMRC, the presence of bacteria in sputum cultures, cardiovascular comorbidity, anaemia, home oxygen therapy, living alone, rural residence, caregiver overload and detecting social-family risks/problems. The variables independently associated with the possibility of PHS were a CAT score >10 (OR, 8.9; P=.04) and detecting a social-family risk/problem (OR, 2.6; P=.04). Active smoking was a predictor of shorter stays (OR, 0.15; P=.002). CONCLUSIONS: Variables related to the social sphere play a relevant role in hospital stays, as do the impact of the disease and the persistent use of tobacco by patients with severe COPD exacerbation.

FDG-PET parameters predicting mediastinal malignancy in lung cancer.

BACKGROUND: Staging of mediastinal lymph nodes in non-small cell lung cancer (NSCLC) is mandatory. The maximum Standard Uptake Value (SUVmax) obtained using F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is the best non-invasive technique available for this evaluation, but its performance varies from center to center. The aim of the present study was to identify FDG-PET predictors of mediastinal malignancy that are able to minimize intercenter variability and improve the selection of subsequent staging procedures. METHOD: A multicenter study of NSCLC patients staged through FDG-PET and endobronchial ultrasonography with needle aspiration (EBUS-NA) was performed using therapeutic surgery with systematic nodal dissection as gold standard. Intercenter variability and predictive power for mediastinal malignancy of different FDG-PET measures were assessed, as well as the role of these measures for selecting additional staging procedures. RESULTS: One hundred and twenty-one NSCLC patients, of whom 94 (72%) had ≥1 hypermetabolic spots in the mediastinum, were included in the study. Mean SUVmax of the primary tumor was 12.3 (SD 6.3), and median SUVmax of the highest hypermetabolic spots in the mediastinum was 3.9 (IQR 2.4-7). Variability of FDG-PET measures between hospitals was statistically significant (p = 0.016 and p < 0.001 respectively), but lost significance when SUVmax in the mediastinum was expressed as a ratio or a subtraction from the primary tumor (SUVmax mediastinum/tumor, p = 0.083; and SUVmax mediastinum - tumor, p = 0.428 respectively). SUVmax mediastinum/tumor showed higher accuracy in the ROC analysis (AUC 0.77 CI 0.68-0.85, p < 0.001), and showed predictive power for mediastinal malignancy when using a 0.4 cutoff (OR 6.62, 95%CI 2.98-14.69). Sensitivities and negative predictive values of clinical staging through EBUS-NA attained values ranging between 57% and 92% after FDG-PET, which improved with additional techniques when the tumor had a diameter >3 cm and/or a SUVmax mediastinum/tumor ratio >0.4. CONCLUSION: The SUVmax mediastinum/tumor ratio is a good predictor of regional tumor extension in NSCLC. This measure is not influenced by intercenter variability and has an accuracy of over 70% for the identification of malignancy when using a 0.4 cutoff.

Effectiveness of a protocolized system to alert pulmonologists of lung cancer radiological suspicion.

PURPOSE: When lung cancer (LC) is suspected in chest radiography, an adequate interpretation and management by experts would improve the selection, the access to rapid diagnostic units, the diagnostic effectiveness and prevent the loss of patients with suspected LC. To ensure this, we planned a system for alerting pulmonologists by radiologists to radiological suspicion of LC. METHODS: This system consists of an alert from radiologists to pulmonologists through a specific email. The pulmonologists alerted has to contact the study doctor petitioner who must refer the patient for study to the Lung Cancer Rapid Diagnostic Unit (LCRDU). We have prospectively analyzed all patients studied in a 2-year period including clinical variables, time invested in the different diagnostic steps and the degree of collaboration and satisfaction among the involved professionals. RESULTS: Of 118 alerts received, 84 (71 %) were studied in our LCRDU. The median of days until petitioner contact, patient consulted at LCRDU and to obtain a diagnosis was 1 (IQR 0-1.5), 2 (IQR 1-5) and 13 (IQR 7.5-30), respectively. In 45 cases (53 %), the suspicion of malignancy was confirmed (LC 84.4 % and metastasic 10.1 %). After staging was complete, 33 % of non-small cell lung cancer was potentially resectable (clinical TNM stage I-II). The level of satisfaction was high so that only one of the petitioner's studies chose other diagnostic pathways. CONCLUSION: This strategy for radiological suspicion of LC ensures the communication between general practitioners, radiologists and pulmonologist improving the LC diagnostic effectiveness. This system can be easily implemented in health care systems.

Calprotectin: a novel biomarker for the diagnosis of pleural effusion.

BACKGROUND: Novel non-invasive biomarkers for the precise diagnosis of malignancy in pleural effusion (PE) are needed. The aim of this study was to determine the diagnostic accuracy of calprotectin for predicting malignancy in patients with exudative PE. METHODS: Calprotectin concentration was measured in 156 individuals diagnosed with exudative PE (67 malignant and 89 benign). Calprotectin accuracy for discriminating between malignant and benign PE was evaluated using receiver operating characteristic (ROC) curves. Univariate and multivariate logistic regression were performed to test the association between calprotectin levels and malignant PE. RESULTS: Calprotectin levels were significantly lower in malignant pleural fluid (257.2 ng ml(-1), range: 90.7-736.4) than benign effusions (2627.1 ng ml(-1), range: 21-9530.1). The area under the curve was 0.963. A cutoff point of ≤ 736.4 ng ml(-1) rendered a sensitivity of 100%, with a specificity of 83.15%, which could prove useful to delimit those patients with negative cytology tests that should be referred for more invasive diagnostic procedures. Logistic regression demonstrated a strong association between calprotectin and malignancy (adjusted OR 663.14). CONCLUSION: Calprotectin predicts malignancy in pleural fluid with high accuracy and could be a good complement to cytological methods.

Validity of procalcitonin and C-reactive protein measurement when differentiating between benign and malignant pleural effusion.

BACKGROUND: Procalcitonin (PCT) and C-reactive protein (CRP) measurements in pleural fluid and plasma have been proposed to facilitate differential diagnosis of pleural effusion (PE). The primary aim of this study was to evaluate the usefulness of these measurements when differentiating between benign (BPE) and malignant pleural effusion (MPE). METHODS: We prospectively studied 100 patients with the specific diagnosis of exudative PE. We analyzed the demographic data and the usual biochemical studies in PE. CRP and PCT were measured in pleural fluid and plasma before starting treatment. RESULTS: The CRP levels in pleural fluid were higher in patients with BPE than in patients with MPE [33.1 mg/L (16.8 to 52.1) vs. 11.8 (5.1 to 22); p = 0.001], as were the plasma CRP levels [68.4 mg/L (26.1 to 119.1) vs. 30.2 (11.7 to 64.8); p = 0.007]. No differences in PCT levels were detected between the two patient populations. The AUC derived from the ROC curve analysis for plasma CRP and pleural fluid CRP were 0.667 (CI 95%: 0.551 - 0.782) and 0.752 (CI 95%: 0.653 - 0.852), respectively. Plasma CRP levels > or = 35.5 mg/L exhibited 71% sensitivity and 56% specificity in discriminating between BPE and MPE. Pleural fluid CRP levels > or = 16.7 mg/L had 75% sensitivity and 68% specificity in the diagnosis of BPE. CONCLUSIONS: CRP levels in the pleural fluid and plasma were higher in patients with BPE, particulary infectious PE. However, the measurement of CRP and PCT is not a useful parameter for discriminating between BPE and MPE and does not provide useful information in clinical practice.

Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.

The aim of the present systematic review was to assess the effectiveness and safety of real time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with suspected or known bronchopulmonary carcinoma, as well as in other clinical indications presented by lymphatic adenopathies. A systematic review was carried out in November 2007 and updated in April 2008 using the main databases. Inclusion and exclusion criteria were applied to the papers retrieved. A total of 20 publications were included. Of these, 14 were original studies that investigated the clinical usefulness of the technique in visualising and staging lymph nodes in patients with suspected or established lung cancer. Sensitivity ranged 85-100% and negative predictive value ranged 11-97.4%. Three studies assessed the clinical usefulness of the technique in the diagnosis of sarcoidosis. EBUS-TBNA was diagnostic in 88-93% of patients. One retrospective study evaluated the use of EBUS-TBNA in the diagnosis of lymphoma. None of the studies included in the present review reported important complications. Endobronchial ultrasound-guided transbronchial needle aspiration is a safe and highly accurate procedure for the examination and staging of mediastinal and hilar lymph nodes in patients with known or suspected lung malignancy. The evidence is promising for sarcoidosis but is not sufficient for lymphoma.

[Tracheal intubation guided by fibrobronchoscopy in patients with difficult airway. Predictive factors of the outcome]. / Intubación traqueal guiada por fibrobroncoscopio en pacientes con vía aérea difícil. Factores predictores del resultado.

INTRODUCTION AND OBJECTIVE: Tracheal intubation (TI) guided by fibrobronchoscopy (FB) is one of the essential techniques in the approach to the difficult airway (DAW). Few works have been published on the possible causes of TI failure with this procedure. This study aims to discover which factors could predict TI failure with FB. MATERIAL AND METHODS: An observational and retrospective study in which the last 122 consecutive TIs guided by FB (between January 2000 and April 2008) performed by our group were included. A multivariate analysis of the factors that could influence in the outcome was conducted: cause of the DAW, TI pathway, type of endotracheal tube, elective or urgent indication of the procedure, sedation level and experience of the bronchoscopist. RESULTS: Tracheal intubation in individuals who are going to undergo surgical interventions accounts for 92.6% of the total. The most frequent indications of TI by FB were: limitation of neck movement (60 cases), airway stenosis (24), increase of soft tissues (13), narrow oral aperture (9), airway compression (6), and vocal cord paralysis (6). In 10 (8.2%) cases, TI by FB was not possible. The variables that best predicted IT failure in the multivariate analysis were profound sedation/ general anesthesia (OR = 12.2; 95% CI, 1.8-84; p = 0.01) and limited experience of the bronchoscopist (OR = 25.3; 95% CI, 3.5-181.8; p = 0.001). CONCLUSIONS: TI guided by FB performed by bronchoscopist is successful in more than 90% of the cases with DAW. The skill and experience of the bronchoscopist is one of the primary determining factors of success of the procedure. Profound sedation may condition TI guided by FB failure.

[Tracheobronchial wall thickening secondary to herpesvirus infection in a patient with Goods syndrome]. / Engrosamiento traqueobronquial producido por herpesvirus en un paciente con síndrome de Good.

We describe an oligosymptomatic patient with Good syndrome (thymoma and hypogammaglobulinemia) in who a follow-up chest computed tomography showed circumferential tracheobronchial wall thickening. Bronchoscopy demonstrated tracheobronchitis with necrotic, vesicular and blister areas. The histopathological and immunohistochemical findings were compatible with herpes simplex virus infection. The therapeutical response to oral acyclovir was satisfactory.

[Transbronchial needle aspiration of diseased mediastinal lymph nodes: predictors of positive findings]. / Factores predictores del resultado de la punción-aspiración transtraqueal de adenopatías mediastínicas neoplásicas.

OBJECTIVE: To assess the factors that may determine the effectiveness of transbronchial needle aspiration through a flexible bronchoscope in the diagnosis of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors. METHODS: Prospective study carried out at 2 hospitals between 1998 and 2004 that included all transbronchial needle aspirations performed on patients who had diseased mediastinal lymph nodes larger than 10 mm and nonlymphoid neoplasms. Univariate and multivariate analysis of the diagnostic results of transbronchial needle aspiration were performed according to the type and location of the primary neoplasm and the lymph node station biopsied, the diameter of the affected node, endoscopic findings, and the results of other bronchoscopic techniques. RESULTS: The study evaluated the transbronchial needle aspiration of 230 lymph node stations in 207 patients. Histologic examination revealed 151 cases (72.9%) of non-small cell lung cancer, 42 cases (20.3%) of small cell lung cancer, and 14 cases (6.8%) of extrapulmonary cancer. The best predictors of obtaining a diagnostic sample were a diameter of the diseased node greater than 20 mm in diameter (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.7; P=.01) and a histologic diagnosis of small cell lung cancer (OR, 2.7; 95% CI, 0.9-8.2; P=.07). CONCLUSIONS: The size of the diseased node and the tumor type are the best predictors of obtaining a diagnostic sample with transbronchial needle aspiration of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

[Pulmonary inflammatory pseudotumor: report of 2 cases and review of the literature]. / Pseudotumor inflamatorio pulmonar: presentación de dos casos y revisión de la literatura.

Inflammatory pseudotumor (IP) of the lung is a rare pathological entity and its ethiopatology is unknown. It is considered to be a benign lesion with an array of histologic appearances. Although, the pulmonary affection is the most frequent, any other organ can be involved. We report two cases de pulmonary IP, one of them endobronchial, and discuss the clinical and anatomopathological features and review the pertinent literature.