Effect of smoking on the diagnostic results and complication rates of percutaneous transthoracic needle biopsy.

OBJECTIVE: To investigate the association of smoking with the outcomes of percutaneous transthoracic needle biopsy (PTNB). METHODS: In total, 4668 PTNBs for pulmonary lesions were retrospectively identified. The associations of smoking status (never, former, current smokers) and smoking intensity (≤ 20, 21-40, > 40 pack-years) with diagnostic results (malignancy, non-diagnostic pathologies, and false-negative results in non-diagnostic pathologies) and complications (pneumothorax and hemoptysis) were assessed using multivariable logistic regression analysis. RESULTS: Among the 4668 PTNBs (median age of the patients, 66 years [interquartile range, 58-74]; 2715 men), malignancies, non-diagnostic pathologies, and specific benign pathologies were identified in 3054 (65.4%), 1282 (27.5%), and 332 PTNBs (7.1%), respectively. False-negative results for malignancy occurred in 20.5% (236/1153) of non-diagnostic pathologies with decidable reference standards. Current smoking was associated with malignancy (adjusted odds ratio [OR], 1.31; 95% confidence interval [CI]: 1.02-1.69; p = 0.03) and false-negative results (OR, 2.64; 95% CI: 1.32-5.28; p = 0.006), while heavy smoking (> 40 pack-years) was associated with non-diagnostic pathologies (OR, 1.69; 95% CI: 1.19-2.40; p = 0.003) and false-negative results (OR, 2.12; 95% CI: 1.17-3.92; p = 0.02). Pneumothorax and hemoptysis occurred in 21.8% (1018/4668) and 10.6% (495/4668) of PTNBs, respectively. Heavy smoking was associated with pneumothorax (OR, 1.33; 95% CI: 1.01-1.74; p = 0.04), while heavy smoking (OR, 0.64; 95% CI: 0.40-0.99; p = 0.048) and current smoking (OR, 0.64; 95% CI: 0.42-0.96; p = 0.04) were inversely associated with hemoptysis. CONCLUSION: Smoking history was associated with the outcomes of PTNBs. Current and heavy smoking increased false-negative results and changed the complication rates of PTNBs. CLINICAL RELEVANCE STATEMENT: Smoking status and intensity were independently associated with the outcomes of PTNBs. Non-diagnostic pathologies should be interpreted cautiously in current or heavy smokers. A patient's smoking history should be ascertained before PTNB to predict and manage complications. KEY POINTS: • Smoking status and intensity might independently contribute to the diagnostic results and complications of PTNBs. • Current and heavy smoking (> 40 pack-years) were independently associated with the outcomes of PTNBs. • Operators need to recognize the association between smoking history and the outcomes of PTNBs.

Prevalence of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization.

OBJECTIVES: To identify the prevalence of non-bronchial systemic culprit arteries and their relationship to bleeding lobes in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization (BAE). METHODS: Data of 83 consecutive patients with bronchiectasis and chronic pulmonary infection (non-tuberculous mycobacteriosis, aspergillosis, and tuberculosis) who underwent de novo BAE between January 2019 and December 2020 were retrospectively reviewed. The prevalence of culprit arteries was investigated. RESULTS: Fifty-five patients (66%) had 172 non-bronchial systemic culprit arteries. The bleeding lobes were the right upper, right middle, right lower, left upper, and left lower lobes in 14 (17%), 20 (24%), 7 (8%), 31 (37%), and 11 (13%) patients, respectively. The internal thoracic (49%; n = 41), intercostal (28%; n = 23), and inferior phrenic (28%; n = 23) arteries were the top three non-bronchial systemic culprit arteries, which were involved in all five types of bleeding lobes. The costocervical trunk and thoracoacromial and lateral thoracic arteries were predominant in patients with upper lobe bleeding. Ligament arteries were predominant in patients with left lower lobe bleeding. CONCLUSIONS: These findings will better ensure the identification of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection. All systemic arteries, especially those which are adjacent to the lung lesions, should be evaluated carefully using MDCT; the internal thoracic, intercostal, and inferior phrenic arteries should be proactively assessed using angiography. KEY POINTS: • Non-bronchial systemic culprit arteries were identified in 66% of patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization. • The internal thoracic (49%), intercostal (28%), and inferior phrenic (28%) arteries were the top three arteries, which were involved in all five types of bleeding lobes. • The costocervical trunk and thoracoacromial and lateral thoracic arteries were prominent in patients with upper lobe bleeding, and the ligament artery was prominent in patients with left lower lobe bleeding.

Association of serum antibodies against the Mycobacterium avium complex and hemoptysis: a cross-sectional study.

BACKGROUND: Hemoptysis is very common and can be life threatening in clinical practice for nontuberculous mycobacteria. The serum antibody against the Mycobacterium avium complex (MAC-Ab), the majority of nontuberculous mycobacteria species, is well known to reflect the activity of MAC lung disease; however, there is no study investigating the association between the MAC-Ab and hemoptysis in MAC patients. Therefore, we assessed whether the MAC-Ab is a good biomarker for hemoptysis among subjects with MAC lung disease. METHODS: This study was conducted as a five-year retrospective survey at the National Hospital Organization Fukuoka National Hospital. A total of 155 patients aged ≥20 years with MAC lung disease were enrolled and separated into seropositive and seronegative groups using the cutoff for MAC-Ab levels of 0.7 U/ml. The prevalence of hemoptysis and odds ratios for the presence of hemoptysis were estimated and compared between the groups. To investigate the linear trends in the relationship between MAC-Ab levels and hemoptysis, the subjects were classified into three groups using the tertile distribution of the MAC-Ab. RESULTS: The prevalence of hemoptysis was twice as high in the seropositive group than in the seronegative group (42.2 and 21.7%, respectively, P = 0.02). The multivariable-adjusted risk of hemoptysis was elevated in the seropositive group as compared with the seronegative group (odds ratio = 2.79 (95% confidence interval 1.15-7.44)). Likewise, when categorizing the subjects into three groups, the risk of hemoptysis increased with increasing MAC-Ab levels (P = 0.03 for trend). CONCLUSIONS: A positive MAC-Ab level was a significant risk factor for hemoptysis among patients with MAC lung disease. There were also positive trends in the association between the MAC-Ab titer and the likelihood of hemoptysis. Measuring the MAC-Ab may contribute not only to early detection of the risk of hemoptysis but also to early intervention with anti-NTM therapy and, as a result, to the prevention of hemoptysis in MAC patients.

Development of a model to predict recurrence after bronchial artery embolization for non-cancer related hemoptysis.

BACKGROUND: Relapse after effective bronchial arterial embolization (BAE) for controlling hemoptysis is not uncommon. Studies reported diverse predictors of recurrence. However, a model to assess the probability of recurrence in non-cancer related hemoptysis patients after BAE has not been reported. This study was to develop a model to predict recurrence after BAE for non-cancer related hemoptysis. METHODS: The study cohort included 487 patients who underwent BAE for non-cancer-related hemoptysis between January 2015 and December 2019. We derived the model's variables from univariate and multivariate Cox regression analyses. The model presented as a nomogram scaled by the proportional regression coefficient of each predictor. Model performance was assessed with respect to discrimination and calibration. RESULTS: One-month and 1-, 2-, 3- and 5-year recurrence-free rates were 94.5%, 88.0%, 81.4%, 76.2% and 73.8%, respectively. Risk factors for recurrence were underlying lung diseases and the presence of systemic arterial-pulmonary circulation shunts. This risk prediction model with two risk factors provided good discrimination (area under curve, 0.69; 95% confidence interval, 0.62-0.76), and lower prediction error (integrated Brier score, 0.143). CONCLUSION: The proposed model based on routinely available clinical and imaging features demonstrates good performance for predicting recurrence of non-cancer-related hemoptysis after BAE. The model may assist clinicians in identifying higher-risk patients to improve the long-term efficacy of BAE.

Pulmonary Arteriovenous Malformations in Non-hereditary Hemorrhagic Telangiectasia Patients: An 18-Year Retrospective Study.

PURPOSE: Pulmonary arteriovenous malformations (PAVMs) are most commonly associated with hereditary hemorrhagic telangiectasia (HHT). Patients with PAVMs can present with serious complications including stroke, transient ischemic attack (TIA), and brain abscess. PAVMs are rare in non-HHT patients and little is known about this patient population. The aim of this retrospective study is to better understand clinical presentation and outcomes of PAVMs occurring exclusively in non-HHT patients. METHODS: Non-HHT patients with PAVMs at the Mayo Clinic-Rochester between 01/01/2000 and 12/31/2018 were reviewed. Patients with Curacao score > 1 were excluded. Demographics, imaging characteristics, neurological complications, and follow-up imaging were analyzed. RESULTS: Seventy-seven patients with PAVMs were identified. The mean age at diagnosis was 48.2 ± 18.3 years with female preponderance (59.7%). The majority of PAVMs had lower lobe predominance (66.7%) and were simple and single in 75.3% and 89.6% of cases, respectively. Most patients were asymptomatic (46.8%) with dyspnea being the most common symptom (28.6%). Neurologic complications occurred in 19.5% of patients. The majority of PAVMs were idiopathic (61%). Thirty patients (39%) had one or more possible risk factors including previous thoracic surgery (23.4%), congenital heart disease (19.5%), and chest trauma (10.4%). Embolization was performed in 37 (48.1%) patients and only 4 (5.2%) underwent surgical resection. CONCLUSIONS: Non-HHT PAVMs occur more commonly in females, are most commonly simple and single, and have lower lobe predominance and a high rate of neurologic complications. Potential predisposing risk factors were identified in about 40% of the cases. Clinicians should be aware of the risk of PAVM development in patients with history of chest trauma, congenital heart disease, lung infection/abscess, and thoracic surgery.

Development of a hemoptysis risk prediction model for patients following CT-guided transthoracic lung biopsy.

BACKGROUND: Computed tomography-guided transthoracic needle biopsy (CT-TNB) is a widely used method for diagnosis of lung diseases; however, CT-TNB-induced bleeding is usually unexpected and this complication can be life-threatening. The aim of this study was to develop and validate a predictive model for hemoptysis following CT-TNB. METHODS: A total of 436 consecutive patients who underwent CT-TNB from June 2016 to December 2017 at a tertiary hospital in China were divided into derivation (n = 307) and validation (n = 129) cohorts. We used LASSO regression to reduce the data dimension, select variables and determine which predictors were entered into the model. Multivariate logistic regression was used to develop the predictive model. The discrimination capacity of the model was evaluated by the area under the receiver operating characteristic curve (AUROC), the calibration curve was used to test the goodness-of-fit of the model, and decision curve analysis was conducted to assess its clinical utility. RESULTS: Five predictive factors (diagnosis of the lesion, lesion characteristics, lesion diameter, procedure time, and puncture distance) selected by LASSO regression analysis were applied to construct the predictive model. The AUC was 0.850 (95% confidence interval [CI], 0.808-0.893) in the derivation, and 0.767 (95% CI, 0.684-0.851) in the validation. The model showed good calibration consistency (p > 0.05). Moreover, decision curve analysis indicated its clinical usefulness. CONCLUSION: We established a predictive model that incorporates lesion features and puncture parameters, which may facilitate the individualized preoperative prediction of hemoptysis following CT-TNB.

Clinical and microbiological characteristics of non-tuberculous mycobacteria diseases in Singapore with a focus on pulmonary disease, 2012-2016.

BACKGROUND: Information on non-tuberculosis mycobacterial (NTM) diseases remains limited in Singapore and other Southeast Asian countries. This study aimed to delineate epidemiological and clinical features of pulmonary NTM disease. METHODS: A retrospective review was performed on all NTM isolates identified in Singapore General Hospital from 2012 to 2016 using the 2007 ATS/IDSA diagnostic criteria. RESULTS: A total of 2026 NTM isolates from 852 patients were identified. M. abscessus-chelonae group (1010, 49.9%) was the most commonly isolated and implicated in pulmonary NTM disease. Pulmonary cases (352, 76%) had the highest prevalence among patients diagnosed with NTM diseases (465/852, 54.6%) with no gender difference. Male patients were older (68.5 years, P = 0.014) with a higher incidence of chronic obstructive pulmonary disease (COPD) (23.6%, P < 0.001) and recurrent cough with phlegm production (51.6%, P = 0.035). In contrast, more female patients had bronchiectasis (50%, P < 0.001) and haemoptysis (37.6%, P = 0.042). Age and COPD were associated with multiple NTM species isolation per patient. CONCLUSIONS: M. abscessus-chelonae group was the commonest NTM species isolated in Singapore. Pulmonary NTM infection has the highest frequency with male and female patients associated with a higher incidence of COPD and bronchiectasis respectively. Age and COPD were associated with multiple NTM species isolation per patient.

Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study.

BACKGROUND: Although tranexamic acid is widely used in patients with haemoptysis, whether it improves mortality has not been well investigated. The aim of this study was to evaluate the effect of tranexamic acid on in-hospital mortality among patients with haemoptysis. METHODS: This was a retrospective study using data from the Japanese Diagnosis Procedure Combination inpatient database. We identified all cases of emergency admission due to haemoptysis from July 2010 to March 2017. Patients were divided into two groups: a control group, and a tranexamic acid group (those who received tranexamic acid on the day of admission). The primary outcome was in-hospital mortality, with secondary outcomes of hospital stay length and total healthcare cost. The data were evaluated using a propensity score matching analysis. RESULTS: Among 28,539 included patients, 17,049 patients received tranexamic acid and 11,490 patients did not. Propensity score analysis generated 9933 matched pairs. Compared to the control group, patients in the tranexamic acid group had significantly lower in-hospital mortality (11.5% vs. 9.0%; risk difference, - 2.5%; 95% confidence interval (CI), - 3.5 to - 1.6%), shorter hospital stays (18 ± 24 days vs. 16 ± 18 days; risk difference, - 2.4 days; 95% CI, - 3.1 to - 1.8 days), and lower total healthcare costs ($7573 ± 10,085 vs. $6757 ± 9127; risk difference, $- 816; 95% CI, $- 1109 to - 523). CONCLUSIONS: Tranexamic acid may reduce in-hospital mortality among patients with haemoptysis requiring emergency admission.

Reconsideration of Dr. Allen's Report about Hemoptysis Patients from High Prevalence of Archaeoparasitological Paragonimiasis in Korea.

Horace N. Allen, an American physician, was a Presbyterian missionary to Korea. In 1886, he wrote the annual report of the Korean government hospital, summarizing patient statistics according to outpatient and inpatient classification for the first ever in Korean history. In the report, he speculated that hemoptysis cases of outpatient might have been mainly caused by distoma. Allen's conjecture was noteworthy because only a few years lapsed since the first scientific report of paragonimiasis. However, he was not sure of his assumption either because it was not evidently supported by proper microscopic or post-mortem examinations. In this letter, we thus revisit his assumption with our parasitological data recently obtained from Joseon period mummies.

Risk of cancer in patients with epistaxis and haemoptysis.

This corrects the article DOI: 10.1038/bjc.2017.85.

Obstructive sleep apnea is the triggering factor for massive hemoptysis : Obstructive sleep apnea and hemoptysis.

PURPOSE: The purpose of this study was to investigate the prevalence of obstructive sleep apnea (OSA) in patients with hemoptysis. METHODS: Files of patients who had undergone bronchial arterial embolization due to hemoptysis between 1 December 2009 and 2015 were evaluated and interviews of patients were conducted until 1 June 2016. Pittsburgh Sleep Quality Index (PSQI), STOP and STOP-BANG surveys were administered. OSA risk was determined with Berlin Questionnaire. RESULTS: Study group consisted of 53 patients and 58 control subjects. Mean age was 46.94 ± 14.36 and 41.97 ± 12.92 in patient and control group, respectively. Of these patients, seven had re-embolization procedure because of recurrence of hemoptysis. High OSA risk was more common among patients with hemoptysis (24.5%, n = 13) than the control group (8.6%, n = 5) (p = 0.023). Percentage of high risk OSA patients with massive hemoptysis, nonmassive hemoptysis, and control subjects was 29.7% (n = 11), 12.5% (n = 2), and 8.6% (n = 5), respectively (p = 0.022). There were more high OSA risk subjects among patients with idiopathic hemoptysis 44.4% (four out of nine), while 20.5% (nine out of 53) patients with a known etiology had high risk (p = 0.127). The number of patients with high OSA risk was also higher in patients who required a second embolization procedure (four out of seven, 57.1%), while 19.6% of patients without need for re-embolization had high risk (p = 0.031). CONCLUSIONS: OSA is found to be a risk factor for hemoptysis and also may provoke massive hemoptysis. It seems reasonable to consider OSA as an underlying condition in idiopathic hemoptysis. OSA may contribute to embolization failure.

Bevacizumab for non-small-cell lung cancer: A nested case control study of risk factors for hemoptysis.

Potentially life-threatening, serious hemoptysis is an adverse event associated with bevacizumab in non-squamous non-small-cell lung cancer (NSCLC) trials. Suggested risk factors include central tumor location and cavitation; however, the profile of hemoptysis occurrence in clinical practice is still unclear. A nested case-control study was conducted to assess the onset profile and risk factors for hemoptysis in bevacizumab-treated patients in a real-world setting in Japan. After bevacizumab was approved for NSCLC, physicians registered all NSCLC patients scheduled for bevacizumab therapy, from November 2009 to August 2011. Patients developing grade 2 hemoptysis requiring an injectable hemostatic agent or grade ≥3 hemoptysis were selected as case subjects, matched with four control subjects each. Case report forms were collected after an observation period of 24 weeks. Radiologists assessed blinded thoracic images. Risk factors for hemoptysis were assessed by univariate and stepwise multivariate analysis. Of 6774 patients registered, 23 (0.3%) experienced grade ≥2 drug-related hemoptysis. A total of 104 patients (21 cases, 83 controls) were analyzed by central reviewers for risk factors of hemoptysis occurrence. In the univariate analysis seven factors were associated with hemoptysis. In the step-wise multivariate analysis, prior thoracic radiotherapy (P = 0.1844), presence of tumor exposure in the central airway (P = 0.0256) and concomitant radiotherapy (P = 0.1169) were identified as risk factors for hemoptysis. While the incidence of hemoptysis was low in the real-world setting in Japan, the three risk factors identified, prior thoracic radiotherapy, presence of tumor exposure in the central airway and concomitant radiotherapy, should be considered when selecting patients for bevacizumab treatment. Although technically classed as a clinical trial, a nested case-control study was a non-interventional surveillance study analyzing all NSCLC patients receiving bevacizumab in Japan, therefore it was not registered as a phase II/III clinical trial would be.

Lung Volume Reduction with Vapor Ablation in the Presence of Incomplete Fissures: 12-Month Results from the STEP-UP Randomized Controlled Study.

BACKGROUND: Emphysema patients with collateral ventilation (CV) will not benefit from valve therapy, the most common endoscopic lung volume reduction procedure. A recent randomized controlled trial (STEP-UP) of the alternative bronchoscopic thermal vapor ablation (BTVA) included patients with (CV+) and without interlobar CV (CV-). OBJECTIVES: This analysis evaluated the efficacy and safety of the CV+ population following BTVA. METHOD: A post hoc fissure analysis of the baseline computed tomography of all treatment and control patients was performed with the VIDA Diagnostics Apollo software. A patient was considered to be CV+ if either of the treated upper lobes was adjacent to a fissure that was <90% complete. The primary endpoints, forced expiratory volume in 1 s (FEV1) and St. George's Respiratory Questionnaire (SGRQ-C), were calculated for these CV+ patients following BTVA and safety results summarized. RESULTS: 78% (35/45) of the patients in the treatment arm and 79% (19/24) of the patients in the control arm were found to be CV+. At 12 months, the FEV1 improvement of the treatment arm was 9.2%, as compared with a decrease of 5.4% in the control group, resulting in a mean between-group difference of 14.6% (p = 0.0137). The improvement in SGRQ-C of the treatment arm as compared to the control arm was 8.4 points (p = 0.0712). An increase in respiratory related serious adverse events was observed immediately following treatment, but most resolved with routine care. CONCLUSION: BTVA can achieve safe and clinically meaningful improvement in pulmonary function and quality of life in patients with CV. These randomized controlled trial subgroup results offer proof of a viable solution for CV+ patients.

Pulmonary hemorrhage in very low birth weight infants: a case-control analysis.

In this case-control analysis, pulmonary hemorrhage cases (n = 22) were more likely than gestational age-matched controls (n = 44) to be small for gestational age, have moderate-to-large patent ductus arteriosus, extubate rapidly, and develop grade III-IV intraventricular hemorrhage (P < .05). Cases were more likely to die (P = .000), especially if not exposed to indomethacin (P = .007).

Association between inhaler use and risk of haemoptysis in patients with non-cystic fibrosis bronchiectasis.

BACKGROUND AND OBJECTIVE: Inhaled medications have been widely applied to patients with airflow limiting non-cystic fibrosis (non-CF) bronchiectasis. However, the association between the use of inhalers and the development of haemoptysis has rarely been explored. The objective of this study was to assess the association between the risk of haemoptysis and the use of inhalers in patients with non-CF bronchiectasis. METHODS: A nested case-control study was performed using a national claims database from 1 January 2009 to 31 December 2011. Inhalers including inhaled corticosteroids (ICS), long-acting ß2 agonists (LABA), long-acting muscarinic antagonists (LAMA), short-acting ß2 agonists (SABA), short-acting muscarinic antagonists (SAMA) and their combinations were tested for the risk of clinically significant haemoptysis events. RESULTS: Among the 62 530 eligible new users of inhalers with non-CF bronchiectasis, 6180 patients with haemoptysis and 27 486 strictly matched controls were selected. In the unadjusted analyses, SAMA, LAMA, SABA and ICS/LABA significantly increased the risk of haemoptysis. After adjustment for other inhaled respiratory medications, comorbidities, health-care utilization and concomitant medications, SAMA, SABA and LAMA consistently increased the risk of haemoptysis (SAMA: odds ratio (OR), 1.6; 95% confidence interval (CI), 1.1-1.4; LAMA: OR, 1.2; 95% CI: 1.1-1.2; SABA: OR, 1.2; 95% CI: 1.1-1.2). The association between anticholinergics (SAMA and LAMA) and risk of haemoptysis showed a dose-dependent trend (P for trend, <0.001). CONCLUSIONS: The use of SABA and inhaled anticholinergics in patients with non-CF bronchiectasis increased the risk of haemoptysis. The risk-benefit ratio of inhaled bronchodilators should be considered in the haemoptysis-susceptible population.

Percutaneous cryoablation for inoperable malignant lung tumors: midterm results.

OBJECTIVE: To retrospectively analyze the efficacy and short- to mid-term survival rate of cryoablation for malignant lung tumors. METHODS: Percutaneous CT-guided cryoablation for 45 malignant lung tumors in 26 patients during 41 sessions from 2009 to 2013 were performed. Follow up CT-scan were used to determine local tumor progression. Survival rate, local tumor control rate and associated risk factors were analyzed. RESULTS: The immediate during and short-term complications with CTCAE grade 2 or upper include pneumothorax (15%), pleural effusion (20%), pulmonary hemorrhage (24%), pneumonitis (15%), hemothorax (15%), hemoptysis (10%), pain (20%), bronchopleural fistula (n=1), and empyema (n=2). Life-threatening bleeding or hemodynamic instability was not observed. There was no procedural-related mortality. Overall survival rate of 1, 2, 3 years are 96%, 88%, 88%. For curative intent, local tumor control (LTC) rate of 1, 2, 3 years are 75%, 72%, 72%. CONCLUSION: Cryoablation for malignant lung tumors is effective and feasible in local control of tumor growth, with good short- to mid-term survival rate, as an alternative option for inoperable patients.

Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients.

BACKGROUND: Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h. METHODS: Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression. CLINICAL COURSE: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death. DISCUSSION: Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk.

BACKGROUND: Pulmonary embolism (PE) can be fatal, but profligate testing for PE can harm patients. OBJECTIVES: With consideration of potential medicolegal implications, this two-part review provides current evidence about the care of patients with suspected and diagnosed PE in the emergency department (ED) setting. DISCUSSION: In part 1, we review published evidence to describe the epidemiology, risk factors, and clinical presentation of PE in the ED setting. Older age, surgery requiring endotracheal intubation within the past 30 days, new use of oral contraceptives, and prior unprovoked venous thromboembolism in nonanticoagulated patients are clear risk factors for PE in ED patients. Recent history of unexplained dyspnea, pleuritic chest pain, and hemoptysis increase probability, but the effect of syncope is less clear. Treated and inactive cancer, smoking, obesity, and pregnancy have not been found to increase the probability of PE in symptomatic ED patients. Unexplained dyspnea, tachycardia, and a low pulse oximetry reading increase probability of PE. Finding of wheezing on lung auscultation reduces the probability of PE, and findings that suggest deep venous thrombosis increase the probability of PE. CONCLUSIONS: Understanding of risk factors, historical data, and physical findings that have been found to increase or decrease the probability of PE in symptomatic ED patients can help create rational guidelines for the diagnostic approach to PE.

Clinical course and prognostic factors of pulmonary aspergilloma.

BACKGROUND AND OBJECTIVE: There is limited data on size change during natural progression of pulmonary aspergilloma. We aimed at elucidating the clinical course and prognosis of aspergilloma according to its size change. METHODS: A multicentre retrospective observational study was performed in 143 adult pulmonary aspergilloma patients with serial chest computed tomography images. The clinical course and risk of haemoptysis according to the size change of the cavity or mass of aspergillomas was evaluated. RESULTS: Median follow-up duration was 5.1 years. The size of aspergillomas changed in 39.2% of study subjects. Decreased and increased volumes of aspergilloma were observed in 13.3% and 25.9%, respectively. Patients with decreased volume had significantly higher C-reactive protein, and more severe bronchiectasis and tuberculosis-destroyed lung. Clinically significant haemoptysis occurred in 50.3% of patients and was significantly associated with the cavity and mass volume of aspergilloma, but not the extent of volume change. A mean cavity diameter of more than 22 mm and a mass diameter of more than 18 mm increased the risk of clinically significant haemoptysis. CONCLUSIONS: A significant portion of pulmonary aspergilloma changed size in our population. The prevalence of clinically significant haemoptysis was associated with absolute size of cavity and mass of aspergilloma.

To correlate clinical and biochemical profile of pleural effusion: a retrospective study in tertiary care centre of central India.

BACKGROUND: Pleural effusion indicates an imbalance between pleural fluid formation and removal. Classified into exudative and transudative, with common symptoms of dry cough, dyspnea and pleuritic chest pain. Confirmed etiology has to be established for effective treatment. OBJECTIVE: Correlate clinical and biochemical profile of various etiologies of pleural effusion. MATERIALS & METHODS: Retrospective observational study of 2 years in the department of respiratory medicine, GMC Bhopal on 280 cases of pleural effusion. RESULTS: Most common etiology was tubercular 202 (72.4%) followed by malignant in 36 (12.8%). With respect to tubercular, malignant pleural effusion has relative risk (RR) of 0.138 (p value < 0.05) in the age group of 51-60 years, which is statistically significant. Patients of tuberculosis complained of fever 158 (78.2%) whereas with malignancy complained of chest pain 16 (44.4%) followed by hemoptysis 12 (33.3%). For hemoptysis, with respect to tubercular, malignant effusion has RR of 5.68 (p value < 0.05) which is significant. History of smoking was significant in malignant effusion with RR of 2.57 (p value < 0.05) as compared to tubercular. Pleural fluid ADA was >70 in 83.7% in tubercular effusion, glucose was <60 mg/dl in 79% tubercular, malignant and bacteriological cause, LDH was >1000 in 88.4% in bacteriological and 72.3% in malignant effusion. CONCLUSION: Lack of tools for confirming diagnosis leads to diagnostic dilemma and delay in treatment initiation, leading to deterioration and untoward fatality in some cases. Our goal is early diagnosis by correlating clinical symptoms with biochemical profile and help initiate rapid treatment.