Auditoría del manejo diagnóstico en pacientes con sospecha de tromboembolismo pulmonar en un Hospital Universitario / Auditing diagnostic management in patients suspected of having pulmonary thromboembolism at a University Hospital

OBJETIVO: conocer la adherencia de los facultativos a las guías de práctica clínica para el diagnóstico del tromboembolismo pulmonar (TEP). Pacientes y método: hemos realizado un análisis retrospectivo de los pacientes sometidos a estudios de imagen pulmonar por sospecha de TEP, gammagrafía de perfusión pulmonar y angiotomografía axial computerizada de tórax multidetector (angio-TAC multidetector), durante el año 2009. Se analizaron la estrategia y los criterios diagnósticos empleados. Una estrategia diagnóstica adecuada y un criterio diagnóstico correcto fueron aquellos que siguieron las guías de práctica clínica (GPC) internacionalmente aceptadas. RESULTADOS: Se han incluido 343 pacientes sometidos a pruebas de imagen pulmonar por sospecha de TEP. En 161 pacientes (46,9%) se realizó gammagrafía de perfusión pulmonar, en 134 (39,1%) angio-TAC torácica multidetector y 48 (14%) se sometieron a ambas pruebas. De los 343 pacientes estudiados, el TEP se confirmó en 95 (27,7%). En 228 (66,5%) no se siguió una estrategia diagnóstica adecuada. Cuando se descarta el TEP, el criterio diagnóstico se consideró incorrecto en un 46% de los pacientes. Cuando se confirma el TEP, el criterio diagnóstico es correcto en el 98,9% de los casos. CONCLUSIONES: El manejo diagnóstico del TEP en la práctica habitual difiere de las recomendaciones que marcan las GPC y sería susceptible de ser mejorado en cuanto a los criterios diagnósticos para descartar la enfermedad y en cuanto a la utilización de recursos y estrategias utilizadas

OBJECTIVE: to determine physicians adherence to clinical practice guidelines for the diagnosis of pulmonary embolism (PE). PATIENTS AND METHODS: we carried out a retrospective analysis of patients undergoing image studies, pulmonary perfusion scintigraphy or computed tomographic pulmonary angiography (CTPA), due to suspicion of PE in 2009. The strategy and the diagnostic criteria used were analyzed. An appropriate diagnostic strategy and proper diagnostic criteria were those wich followed the clinical practice guidelines (CPG) accepted internationally. RESULTS: we included 343 patients undergoing studies of lung image with suspicion of PE. A lung perfusion scintigraphy was performed in 161 patients (46,9%) and a CPTA in 134 (39,1%), 48 patients (14%) underwent both test. PE was confirmed in 95 cases (27,7%) out of the 343 patients under study. In 228 (66,5%) an appropriate diagnostic strategy was not followed. Once the PE is ruled out, the diagnostic criteria was incorrect in 46% of the patients. When PE is confirmed, the diagnosis is correct in 98,9% of the cases. CONCLUSIONS: the management of PE diagnosis in routine practice differs from the recommendations that make CPGs and is able to be improved in terms of the diagnostic criteria for the disease and rule regarding the use of resources and strategies used

Evaluación del efecto de la administración endobronquial de ácido tranexámico (ATx) en el sangrado de vía aérea / Assessment of the effect of endobronchial administration of tranexamic acid (ATx) in airway bleeding

INTRODUCCIÓN: la hemoptisis puede ser espontánea o iatrogénica, durante la broncofibroscopia y toma de muestras. Falta por determinar la efectividad del tratamiento antifibrinolítico con ácido tranexámico (ATx) a nivel endobronquial. OBJETIVOS: valorar la efectividad del ATx por vía endobronquial en la hemoptisis y estudiar las repercusiones del ATx sobre los parámetros de coagulación-fibrinolisis. PACIENTES Y MÉTODOS: se incluyeron 69 pacientes y se establecieron tres grupos: grupo-1 de pacientes con hemoptisis, tratados con ATx (n = 29), grupo-2 de pacientes con neoplasia de pulmón, sin tratamiento local con ATx (n = 20) y grupo-3 de pacientes sin patología neoplásica y sin tratamiento local con ATx (n = 20). Se determinaron niveles séricos basales de TAT (complejo trombina-antitrombina) y DD (dímero-D) 1 hora tras la técnica. Los grupos 2-3 no tratados con ATx, son grupos referencia para valorar la significación de datos obtenidos en los pacientes tratados con ATx. RESULTADOS: el ATx fue efectivo en el 90% de los casos. No se observaron complicaciones inmediatas. La repercusión del ATx sobre el equilibrio coagulación-fibrinólisis es evidente. Los niveles basales séricos de TAT y DD están incrementados en todos los grupos, aunque sin diferencia significativa entre estos. La diferencia en los niveles de TAT entre la determinación basal y la obtenida tras una hora, fue significativa en los tres grupos, más evidente en el grupo-1 (11x superior) tratado con ATx. CONCLUSIONES: el ATx por vía endobronquial es efectivo en la hemoptisis. Este fármaco parece influir en los parámetros de coagulación-fibrinólisis aunque de forma subclínica, dada la ausencia de complicaciones tromboembólicas clínicamente significativas

INTRODUCTION: hemoptysis could be spontaneous or iatroge nic during bronchofiberscopy and when harvesting samples. The effectiveness of anti-fibrinolytic treatment using tranexa mic acid at the endobronchial level has yet to be determined. OBJECTIVES: to assess the effectiveness of endobronchial application of ATx in hemoptysis and study the repercussions of ATx on systemic coagulation- fibrinolysis parameters. PATIENTS AND METHODS: 69 patients were included in the study and three groups were established: Group-1 included patients with hemoptysis treated with ATx (n=29), Group-2 included patients with lung neoplasia without ATx local treatment (n=20) while Group-3 included patients without neoplastic pathology and without ATx local treatment (n=20). Basal levels for TAT (thrombin-anti-thrombin complex) and DD (dimer-D) were determined and one hour after the technique was applied. Groups 2 and 3 were not treated with ATx; they were reference groups to assess the signification of data obtained in patients treated with ATx. RESULTS: ATx was effective in 90% of the cases. No immediate complications were observed. The repercussion of ATx on the coagulation-fibrinolysis is evident. Basal levels for TAT and DD in peripheral venous blood were increased in all groups, although without significant differences among them. The differences in TAT levels between the basal determination and that obtained after one hour was significant in all three groups; it was more evident in Group-1 (11 times greater) which was treated with ATx. CONCLUSIONS: endobronchial application of ATx is effective in hemoptysis. This drug could influence the coagulation-fibrinolysis parameters although sub-clinically, given the absence of clinically significant, thromboembolic complications

Utility of high-resolution computed tomography and BAL in cryptogenic organizing pneumonia.

BACKGROUND: Cryptogenic organizing pneumonia (COP) is a rare disease, and its diagnosis requires histological confirmation. The objective of our study was to describe the findings of the thoracic high-resolution computed tomography (HR-CT) and bronchoalveolar lavage (BAL) in patients with confirmed COP and evaluate the complementary diagnostic use of BAL and thoracic HR-CT. METHODS: Patients recorded in the registry of interstitial pulmonary diseases between 1991 and 2008 were located and the COP patients selected. RESULTS: We identified 21 patients with histological confirmation of COP. The median age was 58.0 ± 15.9 years, and 61.9% of patients were female. The most frequent thoracic HR-CT profile was patchy infiltrate (71.4%), followed by parenchymatous consolidation (42.9%). The most frequent BAL profile was mixed alveolitis (62%) with lymphocyte predominance, a CD4/CD8 index of 0.4 and foamy macrophages. The effectiveness of transbronchial biopsy was 66.6%. The diagnostic utility of Poletti's BAL criteria gives us a specificity of 88.8%, although the sensitivity obtained was low. The specificity of certain HR-CT profiles is 99%. In addition, we observed a complementary use of the HR-CT and the BAL. CONCLUSIONS: The imaging findings and BAL could be useful for patients with appropriate clinical presentation and for those whose transbronchial biopsy is negative or for whom a confirmatory biopsy cannot be performed.