[Management of massive hemoptysis]. / Prise en charge de l'hémoptysie massive.

Less than 5% of all cases of haemoptysis are considered to be massive, representing a life-threatening condition that warrants urgent investigations and treatment. Efforts should be concentrated on determining the origin of the haemoptysis and the presence of an underlying respiratory pathology, in order to ensure supportive measures and a rapid control of the bleeding. Bronchial artery embolization is considered to be the treatment of choice and thoracic surgery should only be considered in cases of localized lesions with a high risk of re-bleeding, pulmonary artery hemorrhage and failure or contraindications to embolization.

Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial.

In this study, we questioned whether propofol provided clinical benefits compared with midazolam in terms of neuropsychometric recovery, safety profile and patient tolerance. Patients, aged >18 yrs, were randomised to receive midazolam or propofol, given by non-anaesthetist physicians to achieve moderate levels of sedation as assessed by the electroencephalographic bispectral index (BIS; between 70 and 85). The primary end-point was the time delay until recovery of the BIS above 90. Other end-points included a neuropsychometric continuous performance test (CPT), serious respiratory adverse events, patient tolerance and physician satisfaction. Neuropsychometric recovery was improved in the propofol compared to the midazolam group as evidenced by faster normalisation of BIS index (5.4+/-4.7 min versus 11.7+/-10.2 min; p = 0.001) and better results at the CPT. In the midazolam group, 15% of patients presented profound sedation precluding CPT completion and one patient required mechanical ventilatory support. Patient tolerance was significantly better in the propofol group, whereas the operator's assessment was comparable in both groups. Compared with midazolam, propofol provided a higher quality of sedation in terms of neuropsychometric recovery and patient tolerance. BIS-guided propofol administration represents a safe sedation technique that can be performed by the non-anaesthesiologist.

Feasibility of the new WHO classification of pulmonary neuroendocrine tumours.

Primary pulmonary neuroendocrine tumours present a heterogeneous group of tumours causing problems in diagnosis and treatment. The new WHO classification of lung tumours was published in 1999 in order to improve this situation by combining morphology, immunohistochemistry and clinical background for diagnosis. The aim of our study was to evaluate the feasibility of this classification and to discuss the consequences of modified diagnostic criteria. 50 cases of neuroendocrine tumours and 50 poorly differentiated lung tumours diagnosed in the years 1981-1994 were independently evaluated by three pathologists. The diagnosis of all 27 typical carcinoids (TC) was given by all authors, however, no unanimous agreement was achieved in one of three atypical carcinoids (AC) and two of four large cell neuroendocrine carcinomas (LCNEC). While typical and atypical carcinoids can be distinguished by the number of mitoses or presence of necrosis it was found that the most difficult diagnostic factor for large cell neuroendocrine carcinoma is the recognition of its light-microscopic neuroendocrine features. In consequence it must be distinguished not only from atypical carcinoid or small cell lung carcinoma (SCLC), but also from poorly differentiated carcinoma. Immunohistochemistry is important for the diagnosis of this entity but also for nonsmall cell lung carcinoma with neuroendocrine differentiation (of which 1 case was detected in our series) There was agreement on the diagnosis of small cell carcinomas in all but one case. The results indicate the excellent reproducibility of the WHO classification.