Changes in lung parenchyma after acute respiratory distress syndrome (ARDS): assessment with high-resolution computed tomography.

The aim of this study was to evaluate the appearance, extent, and distribution of parenchymal changes in the lung after acute respiratory distress syndrome (ARDS) as a function of disease severity and therapeutic procedures. High-resolution computed tomography (HRCT), clinical examination, and lung function tests were performed in 15 patients, 6-10 months after ARDS. The appearance and extent of parenchymal changes were compared with the severity of ARDS, as well as with clinical and therapeutic data. Lung parenchymal changes resembling those found in the presence of pulmonary fibrosis were observed in 13 of 15 patients (87%). The changes were significantly more frequent and more pronounced in the ventral than in the dorsal portions of the lung ( p<0.01). A significant correlation was observed between the extent of lung alterations and the severity of ARDS ( p<0.01), and the duration in which patients had received mechanical ventilation either with a peak inspiratory pressure greater than 30 mmHg ( p<0.05), or with more than 70% oxygen ( p<0.01). Acute respiratory distress syndrome frequently is followed by fibrotic changes in lung parenchyma. The predominantly ventral distribution of these changes indicates that they may be caused by the ventilation regimen and the oxygen therapy rather than by the ARDS.

Tailoring of the lung to overcome size disparities in lung transplantation.

BACKGROUND: Between October 1989 and December 1994 in 13 (four single and nine bilateral lung transplantations) of 124 lung transplantations, pulmonary allografts were considered to be too large to fit into the recipient thoracic cavity. METHODS: In all these patients (emphysema n = 6, fibrosis n = 4, pulmonary hypertension n = 3), the transplanted lungs were trimmed by extra anatomic wedge resections with the use of mechanical stapling devices to reach an acceptable size. RESULTS: No postoperative complication attributable to the tailoring procedure was observed. CONCLUSIONS: Tailoring of the lung is a safe and efficient method to overcome moderate size disparities between donor and recipient lungs.

The role of iodine-123-Tyr-3-octreotide scintigraphy in the staging of small-cell lung cancer.

The purpose of this study is to investigate the role of 123I-Tyr-3-octreotide scintigraphy in staging small-cell lung cancer (SCLC), its efficacy for the discrimination of limited and extensive disease stages and its regional sensitivity for different metastatic locations. Twenty patients with histologically confirmed SCLC and 50 radiologically staged tumors sites were investigated by an imaging protocol including dynamic (0-30 min p.i.), static (30 min, 90 min, 4 hr, 24 hr p.i.) and SPECT (90 min p.i.) studies. The primary tumor site was visualized in 84%, whereas the best delineation was noted in early planar (15-30 min p.i.) and SPECT studies, due to a rapidly decreasing tumor-to-background ratio. Lymph node metastases were seen in 73%, but SPECT was needed for anatomical localization. All three adrenal metastases could be identified in sequential planar images. One clinically unsuspected brain metastasis was seen, whereas a second clinically overt metastasis was not visualized. The global and regional sensitivity for liver and bone metastases was unsatisfactory. In summary, 78% (7/9) of the patients with extensive disease were correctly identified by scintigraphy alone. We conclude that 123I-Tyr-3-octreotide scintigraphy is a substantial tool in the staging work-up of SCLC if it is performed initially to allow fast identification of patients with extensive disease stages and save additional radiological or invasive examinations. Yet, 123I-Tyr-3-octreotide scintigraphy cannot substitute liver sonography or conventional bone scanning in patients who have no scintigraphic evidence of distant tumor spread.

The problems of treating atypical pneumonia.

Atypical pneumonia has been recognized for at least four decades as a clinical syndrome characterized by a less severe clinical course than typical bacterial pneumonia. It is caused by a variety of different organisms including Mycoplasma pneumoniae, chlamydiae, rickettsiae, viruses and Legionella pneumophila. Of the chlamydiae, TWAR-strain (Chlamydia pneumonia) is now considered the most important pathogen. Its prevalence in community-acquired pneumonia varies considerably depending on the cyclical nature of the disease, but also on the diagnostic methods applied. The first line therapy in community-acquired pneumonia is usually empirical administration of a penicillin or cephalosporin to cover the bacterial pathogens which usually cause 'typical' pneumonia, most importantly Streptococcus pneumoniae. If, however, atypical pneumonia is diagnosed by bacteriological or serological testing, or is suspected clinically or on the basis of treatment failure, the treatment of choice would be erythromycin 2-4 g or tetracyclines (doxycycline 200 mg) daily for M. pneumoniae pneumonia and C. pneumoniae (TWAR-strain) infection. For coxiella pneumonia tetracycline is preferred. Psittacosis (ornithosis) has a high mortality and must be treated with tetracyclines immediately. Legionella pneumonia is preferably treated with erythromycin 2-4 g for at least three weeks; as an alternative, tetracyclines or quinolones may be given. Quinolones are less effective in mycoplasma and chlamydial infection. The new macrolide antibiotics are promising agents in pneumonia due to M. pneumoniae, L. pneumophila and C. pneumoniae. Compared to erythromycin they have improved pharmacological properties. They have long half-lives allowing once-daily dosing and achieve high tissue and intracellular concentrations.

Postoperative complication rate of thoracotomy in patients with normal and abnormal pulmonary function.

Recent advances in perioperative monitoring, anesthesia, and postoperative care have resulted in a more generous attitude towards performing thoracic surgery in patients with reduced pulmonary function. In our hospital 100 patients admitted for thoracotomy with or without pulmonary resection were classified on the basis of their pulmonary function: group I (n = 33) normal, group II (n = 40) moderate reduction, group III (n = 27) marked reduction. The mean and standard deviation in groups I, II, and III were: FEV 1 in % VC: 78 +/- 6, 72 +/- 7, and 58 +/- 10; RV in % TLC: 24 +/- 7, 35 +/- 8, and 43 +/- 9; Resistance, kPal/1/sec: 0.2 versus 0.3 versus 0.5. After surgery there were three postoperative deaths from cardiovascular complications without respiratory failure; all 3 patients were in group II and younger than 70 years. Only one patient (classified as group III and 59 years old) died from a respiratory complication (respiratory insufficiency) after a palliative operation on a large adenocarcinoma. Our data demonstrate that markedly reduced preoperative lung function is not necessarily associated with high risk in thoracic surgery--even in elderly persons--provided intensive pre- and postoperative care is guaranteed.

Current issues in the assessment of interstitial lung disease.

Interstitial lung diseases (ILDs) are chronic disorders of the lower respiratory tract, characterized by inflammation and derangement of the alveolar walls. The major functional consequence is the loss of alveolar capillary units and, thus, a limitation of oxygen transfer from air to blood. In recent years, new insights into many aspects of alveolitis as the basic pathological substrate of these diseases, the different inflammatory and immune competent effector cells and their role in the mechanisms of injury and repair have changed our concepts about the pathogenesis of ILD. New techniques, such as bronchoalveolar lavage and computed tomography, allow a better assessment of disease activity and extent of the underlying process. This review also discusses the problems of classification of ILD, and concentrates on issues of assessment and markers of disease activity. Treatment is not a topic of this review but better assessment of these disorders is probably a prerequisite of further progress in treatment and prognosis.

Blood rheology after cardiac valve replacement with mechanical prostheses or bioprostheses.

Arterial thromboembolism is a serious complication in patients after heart valve replacement. Abnormalities in blood rheology may contribute to this complication. Therefore, the aim of this study was to compare various determinants of blood rheology in patients with substitute heart valves with those in healthy controls; furthermore, differences between patients with mechanical valves and those with bioprostheses should be investigated. The hemorrheologic determinants--fibrinogen, plasma viscosity, red cell aggregation, hematocrit and platelet aggregation--were studied in 92 patients with mechanical bileaflet valves, in 28 patients with bioprostheses and in 29 control subjects; the time since valve replacement was greater than or equal to 9 months. Fibrinogen, plasma viscosity, red cell and spontaneous platelet aggregation were found to be increased in all patients after heart valve replacement compared with normal subjects (fibrinogen: 348 +/- 87 vs 267 +/- 66 mg/dl, p less than 0.01; plasma viscosity: 1.71 +/- 0.1 vs 1.66 +/- 0.1 mPas, p less than 0.05; red cell aggregation: 9.9 +/- 2 vs 7.8 +/- 2 U, p less than 0.01; platelet aggregation: 22 +/- 15 vs 13 +/- 13%, p less than 0.01); among patients, fibrinogen, plasma viscosity and spontaneous platelet aggregation were higher in mechanical valves than in bioprostheses (fibrinogen: 359 +/- 95 vs 314 +/- 41 mg/dl, p less than 0.01; plasma viscosity: 1.72 +/- 0.1 vs 1.68 +/- 0.1 mPas, p less than 0.1; platelet aggregation: 23 +/- 15 vs 16 +/- 11%; p less than 0.05), whereas no difference could be found for red cell aggregation (9.7 +/- 2 vs 10.5 +/- 2%, p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

99mTc-anti-CEA radioimmunoscintigraphy of lung adenocarcinoma.

Anti-carcinoembryonic antigen radioimmunoscintigraphy (anti-CEA RIS) in colorectal adenocarcinoma has been reported to allow a better estimation of the local tumor extension than other radiologic methods. This study evaluated the clinical feasibility of a 99mTc-labeled anti-CEA monoclonal antibody (BW 431/26, Behring Institute, FRG) in 11 patients for staging of primary adenocarcinoma of the lung. The primary tumor size ranged from 3 to 8 cm with a mean of 4 cm. Mediastinal and hilar nodes were present in four patients, intrapulmonary metastases were present in two patients, and pleural and liver metastases were present in one patient each. The CEA levels were in the range of 2 to 265 ng/ml and elevated (greater than 5 ng/ml) in six patients. Planar scintigraphy was performed at 6 h and 24 h post injection (pi). Analog and digitized images were interpreted by two observers. One patient was imaged twice and experienced serum sickness due to human anti-mouse antibodies (HAMA) after the second study, which showed marked unspecific tracer uptake in liver, spleen, and bone marrow, but no specific uptake by the tumor and was excluded from further analysis. Visual interpretation identified the primary tumor clearly in seven patients. No tumor imaging was observed in two patients. Two patients were classified as having questionable imaging due to a poor separation of tumor uptake from mediastinal blood pool. The primary tumor could be clearly delineated in both patients after comparison with the chest radiograph. Thus, the overall sensitivity for imaging of the primary tumor was 82 percent. The average target/background ratio was 1.31 +/- 0.17:1 at 6 h pi, and 1.30 +/- 0.16:1 at 24 h pi. Hilar and mediastinal nodes were correctly suspected in three patients, but the cardiac blood pool hampered a clear interpretation. Intrapulmonary and pleural metastases were diagnosed in all cases. The single liver metastasis was missed because of the high unspecific tracer uptake. Planar anti-CEA RIS with 99mTc BW 431/26 was superior to computed tomography (CT) in one case with subtotal tumor resection. We summarize that at present, planar anti-CEA RIS with 99mTc BW 431/26 cannot be advised as a routine staging procedure in adenocarcinoma of the lung, but it may be helpful in the detection of residual or recurrent tumor tissue.

[Uni- and bilateral lung transplantation: functional results. Vienna Lung Transplant Group]. / Uni- und bilaterale Lungentransplantation: Funktionelle Ergebnisse. Vienna Lung Transplant Group.

At the end of December 1990 11 patients had survived lung transplantation at the 2nd Department of Surgery, University of Vienna. In these patients 7 single lung (SLTX) and four bilateral lung transplantations (DLTX) were performed. The indication for operation in 6 cases was emphysema, in 2 cases mucoviscidosis, in 2 cases pulmonary fibrosis, and in 1 case secondary pulmonary hypertension, following operation of a ductus Botalli. By means of fitness tests, blood-gas analysis, pulmonary function tests and ventilation respectively perfusion scan a marked improvement of the clinical status of the patients following lung transplantation could be shown.

[Arteriovenous fistulas of the lung--their clinical aspects and radiologic images]. / Arteriovenöse Fisteln der Lunge--deren Klinik und radiologisches Erscheinungsbild.

Based on the data of 15 patients the typical radiological signs of pulmonary arteriovenous fistulas, their differential diagnostic implications, clinical signs and symptoms and management are reviewed. In addition, lung function parameters of 9 patients are presented. The critical role of pulmonary angiography and sequential dynamic CT for the diagnosis is stressed, particularly in those cases in which conventional chest radiographs and tomographies fail to show characteristics abnormalities. Since pulmonary arteriovenous fistulas tend to increase in size and cause complications, they should be subjected to intermediate treatment, even if they are of no haemodynamic relevance.

Implantation of the Duromedics bileaflet cardiac valve prosthesis in 400 patients.

From September, 1983, to April, 1986, 451 Duromedics bileaflet cardiac valve prostheses were implanted in 400 patients at our institution in Vienna. Aortic valve replacement was done in 190 patients, 157 underwent mitral valve replacement (1 patient also underwent tricuspid valve replacement), 52 underwent double valve replacement, and 1 patient underwent isolated reoperation for tricuspid valve replacement. Concomitant procedures were performed in 86 patients (21.5%). Sixty-one patients (15.2%) had undergone previous cardiac surgery; 32 (8%) had undergone earlier valve replacement. The early mortality rate (within 30 days) was 6.25% (25 patients). Follow-up was done on 337 surviving Austrian citizens; this represents 429 patient-years. The late mortality rate was 2.1% per patient-year (9 patients). We observed paravalvular leak in 3 patients (0.7% per patient-year), thromboembolism in 4 (0.9%), prosthetic valve endocarditis in 5 (1.2%), and anticoagulant-related hemorrhage in 10 (2.3%). Valve failure occurred in 8 patients (1.8%). We conclude, therefore, that good clinical results and a low complication rate can be achieved with this new type of valve.

[Etiology of chronic bronchitis]. / Atiologie der chronischen Bronchitis.

From a synopsis of the large number of epidemiological studies of the recent 20 years it is know, that inhalation of cigarette smoke is the most important factor that generates chronic bronchitis. Other noxious agents about which there are still controversial opinions, are air pollution and occupational inhalants. Although hypersecretion of mucus is the primary symptom of chronic bronchitis, it seems to have no particular prognostic meaning. Whether severe airflow obstruction develops, apparently depends upon predisposing factors such as disturbances of humoral immunity manifested by marked hypogammaglobulinemia or a defect of mucociliary clearance. In recent time increased serum IgE-levels in mom-atopic smokers with bronchial obstructions were reported. Frequent recurrent bronchial infections alone seem to be no serious risk factor. The molecular mechanisms that lead to structural damage are clarified. Activated alveolar macrophages attract polymorphonuclear leucocytes by chemotaxis. These cells set free proteolytic enzymes such as elastases. In addition certain oxidants inhibit the protection system of proteinase inhibitors.

Acute effects of pirenzepin on bronchospasm.

The response to pirenzepin, a new acetylcholine receptor blocking agent, was assessed and compared to placebo in patients with reversible bronchoconstriction. A single intravenous injection of 20 mg of pirenzepin induced a significant reduction of airway resistance compared to placebo (p less than 0.05). The anticholinergic substance pirenzepin appears to be useful in the treatment of bronchospasm.