Assessment of Extensive Airway Obstruction Using Point-by-Point Lateral Pressure Measurements during Bronchoscopy.

BACKGROUND: The positioning of the stent at the flow-limiting segment is crucial for patients with extensive airway obstruction to relieve dyspnea. However, CT and flow-volume curves cannot detect the area of maximal obstruction. OBJECTIVES: The aim of this study is to physiologically evaluate extensive airway obstruction during interventional bronchoscopy. METHODS: We prospectively measured point-by-point lateral airway pressure (Plat) at multiple points from the lower lobe bronchus to the upper trachea using a double-lumen catheter in 5 patients. The site of maximal obstruction was evaluated continuously to measure point-by-point Plat at multiple points when the airway catheter was withdrawn from the lower lobe bronchus to the upper trachea. RESULTS: Remarkable pressure differences occurred at the site of maximal obstruction assessed by point-by-point Plat measurements. After initial stenting in 1 case, migration of the maximal obstruction to a nonstented segment of the weakened airway was seen with extensive stenosis from the trachea to the bronchi. In the second case, in addition to radiological analysis, point-by-point Plat measurements could identify the location of the maximal obstruction which contributed to dyspnea. CONCLUSIONS: Point-by-point Plat measurement could be used to detect the site of maximal obstruction physiologically. Furthermore, Plat measurement could assess the need for additional procedures in real time in patients with extensive airway obstruction.

Assessment of Bronchial Obstruction Using Lateral Pressure Measurement during Bronchoscopy.

BACKGROUND: In patients with bronchial obstruction estimating the location of the maximal obstruction is crucial for guiding interventional bronchoscopy. However, flow-volume curves cannot discriminate between the right and left lungs. OBJECTIVES: The aim of this study was to physiologically evaluate bronchial obstruction during interventional bronchoscopy. METHODS: We prospectively measured lateral airway pressure (Plat) at either side of the obstruction using a double-lumen catheter (pressure-pressure [P-P] curve) simultaneously to assess the degree of bronchial obstruction in 22 patients. The shape of the P-P curve was assessed to confirm the site of maximal obstruction. RESULTS: In the experimental study, Plat was uniform between both bronchi in the normal model. For the unilateral and bilateral obstruction models, a phase shift was only seen for the more obstructed side. In healthy subjects, the angle of the P-P curve was close to 45° and linear in shape. In patients with bronchial obstruction, the angle was much smaller but approached 45° after the bronchoscopic procedure. The degree of bronchial obstruction was significantly correlated with the angle of the P-P curve (r = -0.51, p < 0.01). Dyspnea significantly increased when the airway lumen was obstructed by more than 60% (p < 0.0001), and when the P-P curve appeared loop-shaped (p < 0.01). CONCLUSIONS: The shape of the P-P curve could be used to detect the site of maximal obstruction for the optimal positioning of the stent and assess the need for additional procedures in real time in patients with bronchial obstruction.

Assessing the site of maximal obstruction in the trachea using lateral pressure measurement during bronchoscopy.

RATIONALE: Lateral airway pressure can provide valuable physiological information during bronchoscopy. OBJECTIVES: To evaluate tracheal obstruction during intervention. METHODS: To prospectively measure lateral airway pressure during bronchoscopy using a double-lumen catheter in 15 healthy subjects and 30 patients with tracheal obstruction. Pressure difference was used to evaluate the site of maximal obstruction. The angle between pressure recordings on either side of the stenosis was measured simultaneously (pressure-pressure curves) to assess the degree of tracheal obstruction. MEASUREMENTS AND MAIN RESULTS: In the experimental study, the angle of the pressure-pressure curve was unaffected by breathing maneuvers whereas the pressure difference was affected. In healthy subjects, no pressure difference between the carina and trachea was observed during tidal breathing, and the angle was close to 45°. In patients with tracheal obstruction, the dyspnea scale, pressure difference, and angle changed significantly beyond 50% obstruction (P<0.0001). After stenting, the pressure difference disappeared and the angle was close to 45°. The degree of tracheal obstruction was significantly correlated with the pressure difference (r=0.83, P<0.0001) and angle (r=-0.84, P<0.0001). The cross-sectional area, dyspnea scale, pulmonary function tests, pressure difference, and the angle significantly improved after procedures (P<0.0001). Responder rates on the modified Medical Research Council Scale were 84.6% for obstructions above 80%, and 58.8% for obstructions between 50 and 80%. CONCLUSIONS: The direct measurement of pressure difference and the angle of the pressure-pressure curve represent a new assessment modality for the success of interventional bronchoscopy. Measuring lateral airway pressure could estimate the need for additional procedures better than bronchoscopy alone.

[Clinico-pathological prognostic factors in malignant pleural mesothelioma].

The prognosis of malignant pleural mesothelioma is poor, but selected patients might benefit from multimodality treatment. To establish the means that are available to predict the variable course of the disease in malignant pleural mesothelioma patients, we retrospectively investigated the correlation of clinico-pathological features of 54 patients with survival. Twenty-three patients received treatment, while 31 were referred to supportive care only. The median survival of the entire group was 8.6 months. The 1-year survival was 33.2%. Univariate analysis of subgroups showed that age over 70 years, non-epithelial histologic type, patients treated with supportive care only, and delayed diagnosis were individually associated with lower survival. The European Organization for Research and Treatment of Cancer (EORTC) score showed a significant correlation with survival (P = 0.0146). The median survival of patients with an EORTC score of over 1.27 was 3.5 months, compared to 10.5 months for patients with an EORTC score of 1.27 or less. Tumor necrosis (TN) was a poor prognostic factor on univariate analysis (P = 0.0077). Patients with TN had a median survival of 7.0 months vs 15.5 months in negative cases. On multivariate analysis, TN was determined as an independent prognostic factor (P = 0.0349). EORTC prognostic scoring systems successfully stratify survival for a general hospital population, and TN might play an important role in poor outcome in malignant pleural mesothelioma.

[A case of bronchogenic cyst with elevated SLX levels in serum and cystic fluid].

A 27-year-old man was admitted with chest pain and cough in January 1999. Chest radiograph on admission showed a widened tracheal bifurcation. Computer tomography on admission showed a low density mass located at the tracheal bifurcation. Magnetic resonance imaging of the chest showed a well defined mass with isointensity on T1-weighted images, and high intensity on T2-weighted images. Laboratory data on admission showed mild inflammatory findings and a high level of Sialyl Lewis X-i antigen (SLX) in serum. Thoracotomy revealed a cystic mass and pathologically, the cyst wall was lined with bronchial epithelium which showed no malignancy. The level of SLX in the cystic fluid was elevated, and immunohistochemical staining of the cystic epithelium was positive for SLX. After resection of the cyst, the level of SLX in serum decreased. This represents a rare case of bronchogenic cyst with a high level of SLX in serum and cystic fluid.

Significance of pulmonary artery pressure in emphysema patients with mild-to-moderate hypoxemia.

The guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) do not recommend the measurement of pulmonary artery pressure in patients with chronic obstructive pulmonary disease (COPD). This is on the basis that the mean pulmonary artery pressure (mPAP) does not provide more clinical information than measurement of the oxygen tension in arterial blood (PaO2). The mPAP correlates well with PaO2 in emphysema patients with severe hypoxemia (PaO2 < or = 7.3 kPa (55 mmHg)). However, the occurrence and significance of mPAP is unclear in patients without severe hypoxemia (PaO2 > 7.3 kPa (55 mmHg)). In order to evaluate the usefulness of measurement of mPAP in emphysema patients without severe hypoxemia, we performed right heart catheterization and investigated the pulmonary hemodynamics of 53 patients without severe hypoxemia. In addition, we identified long-term prognostic factors with a mean follow-up term of 77 months after right heart catheterization. Seventeen of 27 patients with mild-to-moderate hypoxemia exhibited pulmonary hypertension (mPAP > or = 2.7 kPa (20 mmHg)) and the classification according to severity in GOLD exhibited a greater correlation to mPAP than PaO2. Moreover, only mPAP was found to be a significant prognostic factor according to multivariate proportional hazards analysis (P = 0.01). We conclude that mPAP is more informative about the severity of emphysema than PaO2 in patients with mild-to-moderate hypoxemia.

[Daily low-dose cisplatin plus concurrent high-dose thoracic radiotherapy in elderly patients with locally advanced unresectable non-small-cell lung cancer].

There are few prospective studies of concurrent chemoradiotherapy in elderly patients with locally advanced unresectable non-small-cell lung cancer (NSCLC), although the therapy has proved superior to radiotherapy alone for the treatment of younger patients. We conducted a pilot study to assess the tolerance and efficacy of concurrent cisplatin and thoracic radiation in elderly patients with locally advanced unresectable NSCLC. Eligible patients were more than 71 years old and had unresectable Stage I, II, or III NSCLC. Cisplatin was administered at 6 mg/m2 daily intravenously on days 1 through 5, days 8 through 12, days 29 through 33 and days 36 through 40. Beginning day on 1, thoracic radiation was delivered at 2.0 Gy daily to a total dose of 60 Gy. Twelve patients were registered and 11 were eligible. Patient characteristics were ages of 73 to 80 years, and stage III A (18%) and stage III B (73%) NSCLC. The most common grade 3 toxicities included leukopenia (20%) and thrombocytopenia (9%). Grades 3/4 elevation of serum creatinin, esophagitis and pneumonitis did not occur. The overall confirmed response rate was 82%, and median overall survival was 23 months. The 2-year survival rate was 53%. This chemoradiotherapy regimen is well tolerated with promising response and survival in elderly patients with unresectable NSCLC.