Intralobar Pulmonary Sequestration Presenting as Chronic Non-productive Cough.

We report a case of a 60-year-old female who was known to have intralobar pulmonary sequestration and her only symptom was chronic cough. She had no history of infections and surgical resection led to complete resolution of her chronic cough.

Critical analysis of common canister programs: a review of cross-functional considerations and health system economics.

Respiratory inhalers constitute a large percentage of hospital pharmacy expenditures. Metered-dose inhaler (MDI) canisters usually contain enough medication to last 2 to 4 weeks, while the average hospital stay for acute hospitalizations of respiratory illnesses is only 4-5 days. Hospital pharmacies are often unable to operationalize relabeling of inhalers at discharge to meet regulatory requirements. This dilemma produces drug wastage. The common canister (CC) approach is a method some hospitals implemented in an effort to minimize the costs associated with this issue. The CC program uses a shared inhaler, an individual one-way valve holding chamber, and a cleaning protocol. This approach has been the subject of considerable controversy. Proponents of the CC approach reported considerable cost savings to their institutions. Opponents of the CC approach are not convinced the benefits outweigh even a minimal risk of cross-contamination since adherence to protocols for hand washing and disinfection of the MDI device cannot be guaranteed to be 100% (pathogens from contaminated devices can enter the respiratory tract through inhalation). Other cost containment strategies, such as unit dose nebulizers, may be useful to realize similar reductions in pharmacy drug costs while minimizing the risks of nosocomial infections and their associated medical costs. The CC strategy may be appropriate for some hospital pharmacies that face budget constraints, but a full evaluation of the risks, benefits, and potential costs should guide those who make hospital policy decisions.

Echocardiography, 6-minute walk distance, and distance-saturation product as predictors of pulmonary arterial hypertension in idiopathic pulmonary fibrosis.

BACKGROUND: Pulmonary arterial hypertension (PAH) is frequently seen in patients with idiopathic pulmonary fibrosis (IPF). We sought to examine the performance of echocardiography, 6-min walk test (6MWT) distance, distance-saturation product (DSP), and pulse oximetry (SpO2) in detecting underlying PAH in IPF. METHODS: 626 lung transplanted patients from February 1990 to December 2007 were considered. Subjects with pre-transplant diagnosis of IPF were evaluated. Based on findings in pre-transplant right heart catheterization, the presence or absence of PAH was recorded. Right-ventricle systolic pressure, 6MWT distance, DSP, and lowest SpO2 during 6MWT were compared in PAH and non-PAH groups. Receiver operating characteristic curves for each variable to assess prediction of PAH were constructed. RESULTS: 131 patients were transplanted due to IPF. Of these 131 patients, 58 (44%) were eligible. PAH was diagnosed by right heart catheterization in 25 (43%) of 58 eligible patients. The mean pulmonary arterial pressure in PAH patients was 33 mm Hg, and 19 mm Hg in non-PAH patients (P = .001). 6MWT distance was 321 m in the PAH group, and 346 m in the non-PAH one (P = .38). DSP in PAH subjects was 272 meters% and 286 meters% in those with no PAH (P = .57). The lowest SpO2 in the PAH and non-PAH groups were 84% and 82%, respectively (P = .38). The diagnostic accuracy of the echocardiography exceeded that of the other variables (area under the curve 0.72). CONCLUSIONS: Right-ventricle systolic pressure measured by echocardiography, by 6MWT distance, by DSP, or by SpO2 performs poorly in detecting PAH in IPF. Measured by right heart catheterization, right-ventricle systolic pressure performs better to predict PAH in IPF.

Detection of upper airway obstruction with spirometry results and the flow-volume loop: a comparison of quantitative and visual inspection criteria.

BACKGROUND: There are important gaps in our understanding of the epidemiology and diagnosis of upper-airway obstruction. METHODS: We examined the diagnostic value of several criteria for predicting upper-airway obstruction, and we measured the frequency of detecting upper-airway obstruction via quantitative and visual assessment of flow-volume loops. We studied 4 quantitative and 3 visual criteria for their ability to detect upper-airway obstruction. The quantitative criteria were: ratio of forced expiratory volume in the first second (FEV(1)) to maximum expiratory flow (MEF) > 10 mL/L/min; ratio of the flow at the mid-point of the forced expiratory maneuver (MEF(50%)) to the flow at the mid-point of the forced inspiratory maneuver (MIF(50%)) < 0.3 or > 1; MIF(50%) < 100 L/min; and FEV(1)/FEV(0.5) > 1.5. The visual criteria were: presence of a plateau; biphasic shape; and oscillations. The accepted standard tests for diagnosing upper-airway obstruction were bronchoscopy, laryngoscopy, and chest or neck computed tomogram. We considered 979 consecutive flow-volume loops from the Cleveland Clinic's pulmonary function laboratory. We calculated the sensitivity, specificity, and positive and negative predictive values of the individual criteria and an aggregate criterion for predicting upper-airway obstruction. RESULTS: We excluded 504 flow-volume loops because the workups for those patients did not include any of the accepted standard tests for diagnosing upper-airway obstruction, so there were 475 eligible flow-volume loops (48.6% of the 979 loops considered). Thirty-six (7.5%) of the 475 workups that included an accepted standard test reported a cause of upper-airway obstruction. The aggregate sensitivity for detecting upper-airway obstruction was 69.4%. Receiver-operating-curve analysis found that the individual criteria had poor diagnostic performance (area under the curve < 0.522) but that a newly proposed aggregate criterion performed better (area under the curve 0.605). CONCLUSIONS: The prevalence of reported upper-airway obstruction was 7.5%. The quantitative criteria showed low sensitivity for detecting upper-airway obstruction but exceeded that of visual criteria. The aggregate criterion increased the sensitivity to 69.4%, which suggests the need for additional criteria to help predict upper-airway obstruction.