Diagnostic Accuracy and Safety of CT-Guided Percutaneous Transthoracic Needle Biopsies: 14-Gauge versus 22-Gauge Needles.

PURPOSE: To compare the diagnostic accuracy and safety of a 14-gauge core needle versus a 22-gauge fine needle in the evaluation of thoracic lesions by CT-guided percutaneous transthoracic needle biopsy (TTNB). MATERIALS AND METHODS: Medical charts of all patients who underwent CT-guided percutaneous transthoracic core-needle biopsies (CNBs) with a 14-gauge Spirotome device (99 patients, 102 procedures) and fine-needle biopsies (FNBs) with a 22-gauge Rotex needle (92 patients, 102 procedures) between 2007 and 2013 at a single academic institution were retrospectively reviewed. Variables that could influence diagnostic accuracy and safety were collected. RESULTS: The overall and cancer-specific diagnostic accuracy rates were 90% and 94%, respectively, with CNB, versus 82% and 89% with FNB. Precise cancer type/subtype was provided by 97% of CNBs versus 65% of FNBs (P < .001). In patients with lung cancer considered for targeted therapy, biomarker analyses were feasible in 80% of CNBs versus 0% of FNBs (P < .001). The rate of pneumothorax was significantly higher with CNB versus FNB (31% vs 19%; P = .004), but chest tube insertion rates were similar (10% vs 11%, respectively). Major bleeding complications occurred in 1% of CNBs versus 2% of FNBs and were associated with one death in the CNB group. CONCLUSIONS: Percutaneous transthoracic CNB with a 14-gauge Spirotome needle provided better characterization of cancer lesions and allowed biomarker analyses without a significant increase in major procedural complications.

Sartan-induced interstitial lung disease.

Background: Lung toxicity of angiotensin receptor blockers (sartans) have very seldom been reported in the literature despite their wide use. We here report a case of interstitial lung disease elicited by sartans, with two episodes induced by two different sartans at 10 years of interval. Case presentation: In 2012, eprosartan was the very likely cause of a drug induced interstitial lung disease in a 60 year old man. Indeed, his symptoms, consisting in a MMRC2 dyspnea and recurrent hemoptysis, completely disappeared after the removal of this drug. When the circumstances rendered it necessary to start another angiotensin receptor blocker (namely valsartan) ten years later we did not expect the same reaction to occur given among other things a very poor literature on the topic. After a few months with this medication, he however developed similar symptoms and a Chest CT imaging that was comparable to what he had in 2012.This time also the clinical picture resolved completely when the sartan was stopped. Conclusion: We report this first case of a drug induced interstitial lung disease induced by two different angiotensin receptor blockers (sartans) with a new drug challenge ten years after the first one.

[The cardiac lung]. / Poumon cardiaque.

Since lungs, great vessels and heart share together the main volume of the thorax, itself limited by the thoracic wall, variations in pressure or volume of each one must influence the work of the others especially in case of disease. Failure of the left heart overloads the pulmonary vascular bed, induces an interstitial oedema followed by an alveolar oedema with mostly restrictive functional consequences on the lung and disturbed gas exchange. Heart failure can be due to systolic or diastolic dysfunction. These consequences of myocardial and valve diseases of the left heart are initially revealed by unusual dyspnea during exercise worsening progressively to symptoms at rest and even during sleep. Informations obtained from history, physical examination, biology, radiography and echocardiography imaging procedures, respiratory function tests and polysomnography help to precise the diagnosis and the prognosis. The treatment of this cardiac lung conditions depends on its precise etiology.

Effects of nasal pressure support on ventilation and inspiratory work in normocapnic and hypercapnic patients with stable COPD.

OBJECTIVES: To assess and compare the effect of nasal continuous positive airway pressure (nCPAP), inspiratory pressure support (PSV), and bilevel positive airway pressure (biPAP) on ventilatory parameters and inspiratory work (WOB) in normocapnic and hypercapnic patients with stable COPD. METHODS: While administering nasal pressure support to 10 normocapnic and 10 hypercapnic patients with COPD, we measured airflow and volume with a pneumotachograph as well as esophageal and gastric pressures under nCPAP, PSV, and biPAP conditions. RESULTS: nCPAP had no influence on ventilatory parameters but decreased WOB and transdiaphragmatic work (Wdi) at 10 cm H(2)O of pressure in both groups. With PSV and biPAP, ventilatory parameters increased proportionally to the inspiratory applied pressure. WOB and Wdi decreased significantly in both groups while increasing the pressure support. A similar decrease was observed during biPAP proportionally to the level of pressure support. The diaphragmatic pressure-time product decreased similarly in both groups during PSV and biPAP. CONCLUSION: The ventilatory response under nCPAP, PSV, and biPAP conditions is similar in hypercapnic and normocapnic patients with stable COPD; PSV and biPAP increase ventilatory parameters and improve Wdi. On the contrary, nCPAP improves WOB but does not increase ventilatory parameters.

Mechanisms in pulmonary toxicology.

Specific accumulation and biotransformation of drugs cause cell injury in the lung. Evoked mechanisms are oxidative injury, direct cytotoxic effects, intracellular deposition of phospholipids, and immune reaction. Individual susceptibility can be due to genetically determined metabolic idiosyncrasy or to immune-mediated hypersensitivity.

F-18 FDG PET/CT findings in pulmonary necrotizing sarcoid granulomatosis.

Necrotizing sarcoid granulomatosis (NSG) is a rare systemic disease that was described by Liebow in 1973. Dyspnea and chest pain may be present, as in our first patient; however, 25% of patients are asymptomatic, as our second patient. The typical radiographic findings are nonspecific: single or multiple lung opacities, with common involvement of the pleura. To the best of our knowledge, fluorodeoxyglucose (FDG) PET has only been reported in one case of NSG, which was atypical as it occurred in an adolescent. We report 2 cases, confirming that the lesions of NSG are FDG positive, showing a typical pattern of multiple bilateral lung nodules (imaged with PET/CT in 1 case). FDG imaging has a potential role when this distribution is observed on CT, to guide the surgical biopsy and show the actual extent of the disease.

Evaluation of flow limitation in elderly patients unable to perform a forced expiratory maneuver.

BACKGROUND AND AIMS: The assessment of pulmonary function in elderly persons is not often easy in the clinical practice because of poor patient collaboration. A new technique, negative expiratory pressure (NEP), should provide a simple, rapid and non-invasive method for detecting flow limitation without collaboration of the patients. Our aim was to investigate whether it is possible to detect an expiratory flow limitation during resting breathing with NEP in elderly patients unable to perform a forced expiratory maneuver. METHODS: In 15 elderly inpatients (4 males and 11 females, mean age 83+/-4.7 SD years) unable to realize the classical forced expiratory maneuver because of poor coordination or cognitive disturbance, we applied the NEP technique during spontaneous breathing. RESULTS: NEP application during resting breathing was easily and rapidly performed in all cases without side effects. During NEP (-5cmH2O and NEP -10cmH2O), 6 and 5/15 patients were flow limited; mean flow limitation was 60+/-9% and 70+/-15% respectively. These results were reproducible with repeated NEP tests. CONCLUSIONS: Application of negative pressure at the mouth during tidal expiration provides a simple method for detecting expiratory flow limitation during spontaneous breathing in elderly patients with poor collaboration.

Influence of respiratory behavior on ventilation, respiratory work and intrinsic PEEP during noninvasive nasal pressure support ventilation in normal subjects.

BACKGROUND: In clinical practice, patients have different inspiratory behaviors during noninvasive pressure support ventilation (PSV): some breathe quietly, others actively help PSV by an additional effort, and others even resist the inspiratory pressure of PSV. OBJECTIVE: What is the influence of patient collaboration (inspiratory behavior) on the efficiency of PSV? METHODS: We ventilated 10 normal subjects with nasal PSV (inspiratory/expiratory: 10/0 and 15/5 cm H(2)O) and measured their flow and volume with a pneumotachograph and their esophageal and gastric pressures during three different respiratory voluntary behaviors: relaxed inspiration, active inspiratory work and resisted inspiration. RESULTS: When compared with relaxed inspiration with 10/0 cm H(2)O PSV: (1) an active inspiratory effort increased tidal volume (from 789 +/- 356 to 1,046 +/- 586 ml; p = 0.006), minute ventilation (from 10.40 +/- 4.45 to 15.77 +/- 7.69 liters/min; p < 0.001), transdiaphragmatic work per cycle (from 0.55 +/- 0.33 to 1.72 +/- 1.40 J/cycle; p = 0.002) and inspiratory work per cycle (from 0.14 +/- 0.20 to 1.26 +/- 1.01 J/cycle; p = 0.003); intrinsic positive end-expiratory pressure (PEEP(i)) increased from 1.23 +/- 1.02 to 3.17 +/- 2.30 cm H(2)O; p = 0.002); (2) a resisted inspiration decreased tidal volume (to 457 +/- 230 ml; p = 0.007), minute ventilation (to 6.93 +/- 3.04 liters/min; p = 0.028) along with a decrease in transdiaphragmatic work but no change in PEEP(i). Data obtained during a bilevel PSV of 15/5 cm H(2)O were similar to those obtained with the 10/0 cm H(2)O settings. CONCLUSIONS: Active inspiratory effort increases ventilation during PSV at the expense of an increased breathing work and PEEP(i). Resisted inspiration inversely decreases inspiratory work and ventilation with no air trapping. These differences between inspiratory behaviors could affect the expected beneficial effects of PSV in acutely ill patients.