Validity of lung ultrasound to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure.

INTRODUCTION: Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of lung ultrasound, conducted by pulmonologists without experience in this procedure, to tule out pneumothorax after invasive procedures. MATERIAL AND METHODS: Our prospective observational study consecutively included patients who underwent transbronchial lung biopsy (TBLB), therapeutic thoracentesis (TT) and/or transparietal pleural biopsies (PB) for whom subsequent chest radiography to rule out complications was indicated. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered in the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the "barcode" sign. RESULTS: We included 275 procedures (149 TBLBs, 36 BPs, 90 TTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. CONCLUSIONS: Lung ultrasound performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.

Validez de la ecografía torácica para descartar neumotórax iatrogénico realizada por neumólogos sin experiencia en este procedimiento / Validity of lung ultrasound to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure

Introducción La ecografía ha demostrado ser una herramienta útil para el diagnóstico del neumotórax en manos expertas. Tras los procedimientos broncopleurales se recomienda realizar una radiografía de tórax para descartar complicaciones. Nuestro objetivo ha sido determinar la validez de la ecografía torácica para descartar neumotórax tras procedimientos invasivos, realizada por neumólogos sin experiencia en este procedimiento. Material y métodos Estudio observacional prospectivo que incluyó pacientes consecutivos sometidos a biopsia transbronquial (BTB), toracocentesis evacuadora (TE) y/o biopsias pleurales transparietales (BPT) a los que se les indicó radiografía de tórax posterior para descartar complicaciones. En todos los casos el mismo neumólogo que hizo la técnica, realizó una ecografía inmediatamente después del procedimiento. Se consideró diagnóstica de neumotórax la presencia de punto pulmonar o la combinación de los signos: ausencia de deslizamiento pleural, ausencia de líneas B y presencia del signo de «código de barras». Resultados Se incluyeron 275 procedimientos (149 BTB, 36 BPT, 90 TE) entre los que se produjeron 14 (5,1%) neumotórax iatrogénicos. La ecografía presentó una sensibilidad de 78,5%, una especificidad de 85%, y un valor predictivo positivo y negativo de 22% y 98,6%, respectivamente. La ecografía no permitió detectar la presencia de tres neumotórax, precisando uno de ellos drenaje torácico y diagnosticó adecuadamente dos neumotórax que no se detectaban en la radiografía inicial. Conclusiones La ecografía torácica realizada por neumólogos que inician su curva de aprendizaje permite descartar neumotórax con un valor predictivo negativo (VPN) del 98,6%, evitando realizar en un número considerable de casos estudios radiográficos de control innecesarios (AU)

Introduction Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of lung ultrasound, conducted by pulmonologists without experience in this procedure, to rule out pneumothorax after invasive procedures. Material and methods Our prospective observational study consecutively included patients who underwent transbronchial lung biopsy (TBLB), therapeutic thoracentesis (TT) and/or transparietal pleural biopsies (PB) for whom subsequent chest radiography to rule out complications was indicated. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered in the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the “barcode” sign. Results We included 275 procedures (149 TBLBs, 36 BPs, 90 TTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. Conclusions Lung ultrasound performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases (AU)

Validity of thoracic ultrasonography to rule out iatrogenic pneumothorax performed by pulmonologists without experience in this procedure. / Validez de la ecografía torácica para descartar neumotórax iatrogénico realizada por neumólogos sin experiencia en este procedimiento.

INTRODUCTION: Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of thoracic ultrasonography to rule out pneumothorax after invasive procedures, conducted by pulmonologists without experience in this procedure. MATERIAL AND METHODS: Our observational prospective study consecutively included patients who underwent transbronchial biopsy (TBB), evacuating thoracentesis (ECT) and/or transparietal pleural biopsies (TPB) who were indicated subsequent chest radiography to rule out complications. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the «barcode¼ sign. RESULTS: We included 275 procedures (149 TBBs, 36 TPBs, 90 ECTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and a positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. CONCLUSIONS: Thoracic ultrasonography performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.

[Tracheobronchial wall thickening secondary to herpesvirus infection in a patient with Goods syndrome]. / Engrosamiento traqueobronquial producido por herpesvirus en un paciente con síndrome de Good.

We describe an oligosymptomatic patient with Good syndrome (thymoma and hypogammaglobulinemia) in who a follow-up chest computed tomography showed circumferential tracheobronchial wall thickening. Bronchoscopy demonstrated tracheobronchitis with necrotic, vesicular and blister areas. The histopathological and immunohistochemical findings were compatible with herpes simplex virus infection. The therapeutical response to oral acyclovir was satisfactory.

Engrosamiento traqueobronquial producido por herpesvirus en un paciente con síndrome de Good / Tracheobronchial wall tickening secondary to herpesvirus infection in a patient with good syndrome

Se decribe el caso de un paciente con síndrome de Good (timoma e hipogammaglobulinemia), que estando oligosintomático, se le realizó una tomografía computerizada de tórax de control en la que se evidenció un engrosamiento circunferencial de la pared traqueobronquial. Una broncoscopia demostró datos de una traqueobronquitis con áreas necróticas y vesículo-ampollosas, siendo los hallazgos histopatológicos y de inmunohistoquímica compatibles con una infección por el virus del herpes simple. La respuesta terapéutica al aciclovir oral fue satisfactoria

We describe an oligosymptomatic patient with Good syndrome (thymomaand hypogammaglobulinemia) in who a follow-up chest computed tomography showed circumferential tracheobronchial wall thickening. Bronchoscopy demonstrated tracheobronchitis with necrotic, vesicular and blister areas. The histopathological and immunohistochemical findings were compatible with herpes simplex virus infection. The therapeutical response to oral acyclovir was satisfactory

[Factors determining the duration of temporary disability and return to work in a health district of Galicia]. / Determinantes de la duración de la incapacidad temporal y la vuelta al trabajo en un área sanitaria de Galicia.

OBJECTIVE: To determine the factors associated with the incidence and duration of temporary work incapacity (TWI) in a health district. DESIGN: Descriptive and retrospective study. SETTING: South health district of the province of Lugo, Spain. PARTICIPANTS: A random sample of 1513 cases was selected among the total of episodes of TWI, during 3 years period. MAIN MEASURES: The main factors analyzed are, on the one hand, the socio-demographic characteristics of the patient, his or her social security (SS) scheme, diagnosis that justifies the TWD, and the prescription date; and, on the other hand, the age, sex, specialised training, time in the post and years in practice of the physician who prescribes the TWI. The comparison of the means was carried out using variance analysis and the Kruskal-Wallis test. The relative effect of each variable on the probability of returning to the work was estimated through Cox regression models. RESULTS: The mean duration of the episodes of TWI was of 74+/-103 days. The most frequent diagnoses were those of the bones-muscles and joints (BMAJ), injuries and poisonings (IAP), and respiratory diseases (RD). The probability of returning to work is reduced with the increase of the age, with agrarian and autonomous SS affiliates, with diagnoses of mental disease or diagnoses of the circulatory system, and in cases prescribed by older doctors or less time in the post. CONCLUSIONS: The mean duration of the episodes of TWD is higher than that of other Spanish studies. The most influential factors in the return to work are the age of the patient, the SS scheme and the diagnosed illness.

Determinantes de la duración de la incapacidad temporal y la vuelta al trabajo en un área sanitaria de Galicia / Factors determining the duration of temporary disability and return to work in a health district of Galicia

Objetivo. Determinar los factores asociados con la incidencia y la duración de la incapacidad temporal (IT) en un área sanitaria. Diseño. Descriptivo, retrospectivo. Emplazamiento. Área Sanitaria Sur de la provincia de Lugo. Participantes. Una muestra de 1.513 episodios de IT seleccionada aleatoriamente entre el total de éstos, durante un período de 3 años. Mediciones principales. Se analizaron las características sociodemográficas del paciente, el régimen de la seguridad social (SS), el diagnóstico que justifica la IT y la fecha de la prescripción; del médico prescriptor se analizaron la edad, el sexo, la formación especializada, la antigüedad en la plaza y los años de ejercicio. La comparación de medias se realizó mediante el análisis de la varianza y el test de Kruskal-Wallis. El efecto relativo de cada variable sobre la probabilidad de volver al trabajo se estimó mediante modelos de regresión de Cox. Resultados. La duración media de los episodios de IT fue de 74 ± 103 días. Los diagnósticos más frecuentes fueron los del sistema osteomioarticular (SOMA), las lesiones y envenenamientos (LYE) y las enfermedades respiratorias (NML). Se reduce la probabilidad de volver al trabajo con el incremento de la edad, en los regímenes de seguridad social autónomos y agrarios por cuenta propia, en los diagnósticos de enfermedades mentales y del aparato circulatorio, y cuando el médico prescriptor es de mayor edad o menos antiguo en la plaza. Conclusiones. La duración media de los episodios de IT es superior a la de otros estudios españoles. Los factores que más influyen en la reincorporación al trabajo son la edad del paciente, el régimen de la seguridad social y la enfermedad diagnosticada

Objective. To determine the factors associated with the incidence and duration of temporary work incapacity (TWI) in a health district. Design. Descriptive and retrospective study. Setting. South health district of the province of Lugo, Spain. Participants. A random sample of 1513 cases was selected among the total of episodes of TWI, during 3 years period. Main measures. The main factors analyzed are, on the one hand, the socio-demographic characteristics of the patient, his or her social security (SS) scheme, diagnosis that justifies the TWD, and the prescription date; and, on the other hand, the age, sex, specialised training, time in the post and years in practice of the physician who prescribes the TWI. The comparison of the means was carried out using variance analysis and the Kruskal-Wallis test. The relative effect of each variable on the probability of returning to the work was estimated through Cox regression models. Results. The mean duration of the episodes of TWI was of 74±103 days. The most frequent diagnoses were those of the bones-muscles and joints (BMAJ), injuries and poisonings (IAP), and respiratory diseases (RD). The probability of returning to work is reduced with the increase of the age, with agrarian and autonomous SS affiliates, with diagnoses of mental disease or diagnoses of the circulatory system, and in cases prescribed by older doctors or less time in the post. Conclusions. The mean duration of the episodes of TWD is higher than that of other Spanish studies. The most influential factors in the return to work are the age of the patient, the SS scheme and the diagnosed illness

[Bronchodilator efficacy of combined salmeterol and tiotropium in patients with chronic obstructive pulmonary disease]. / Eficacia broncodilatadora de la asociación de salmeterol y tiotropio en pacientes con EPOC.

OBJECTIVE: Bronchodilators are still the most effective drugs for controlling the symptoms of chronic obstructive pulmonary disease (COPD). Tiotropium bromide, a long-acting anticholinergic drug, has recently been added to the therapeutic arsenal for the disease. To date, there have been no studies combining 2 long-acting bronchodilators. The aim of the present trial was to determine whether the combination of salmeterol and tiotropium improved lung function in COPD patients more than either of them alone. PATIENTS AND METHODS: Twenty-two patients (20 men) diagnosed with COPD, with a mean age of 64 years, were enrolled in this cross-over trial. Active smokers were excluded. Mean (SD) forced expiratory volume in 1 second (FEV1) was 43% (14%) of predicted. All patients were experienced in the use of inhalers. The following 3 therapeutic combinations were randomly assigned to be administered for a 1-week period: a) fluticasone (500 microg/12 h), salmeterol (50 microg/12 h) and placebo; b) fluticasone, tiotropium (18 microg/24 h), and placebo; and c) fluticasone, salmeterol, and tiotropium. At the end of each period, forced spirometry was performed before inhalation of the therapeutic combination (between 8:30 am and 9:30 am) and 2 hours after inhalation. Throughout the week, morning peak flow rates measured immediately before inhalation were recorded, and there was a 48-hour wash-out period between each therapeutic combination. RESULTS: All the patients completed the protocol. There were no significant differences in preinhalation or postinhalation FEV1 with salmeterol compared to tiotropium (preinhalation FEV1, 1.17 [0.55] L compared to 1.19 [0.49] L; postinhalation FEV1, 1.32 [0.65] L compared to 1.29 [0.61] L). In all cases postinhalation FEV1 was significantly higher than preinhalation FEV1. The combination of fluticasone, salmeterol, and tiotropium proved superior to the other 2 combinations with respect to both preinhalation FEV1 and postinhalation FEV1 (preinhalation FEV1, 1.32 [0.56] L, [P<.03 in both comparisons]; postinhalation FEV1, 1.49 [0.68] L [P<.001 in both comparisons]). Peak flow rate was also significantly higher with the combination of the 2 bronchodilators (345 L/min compared to 291 L/min and 311 mL, respectively [P <.04 in both cases]). There were no notable side effects. CONCLUSIONS: In terms of improvement in lung function, the combination of salmeterol and tiotropium together with fluticasone is more effective in patients with moderate-to-severe COPD than either of the 2 bronchodilators administered alone.

Eficacia broncodilatadora de la asociación de salmeterol y tiotropio en pacientes con EPOC / Bronchodilator efficacy of combined salmeterol and tiotropium in patients with chronic obstructive pulmonary disease

OBJETIVO: Los broncodilatadores continúan siendo los fármacos más eficaces para el control de los síntomas de la enfermedad pulmonar obstructiva crónica (EPOC). Recientemente se ha añadido un anticolinérgico de acción larga, el bromuro de tiotropio, al arsenal terapéutico de esta enfermedad. No existen estudios que hayan asociado 2 broncodilatadores de acción sostenida. El objetivo de este estudio ha sido comprobar si la asociación de salmeterol y tiotropio a pacientes con EPOC mejora la función pulmonar respecto a cuando se administran aislados. PACIENTES Y MÉTODOS: Se incluyó en el estudio a 22 pacientes diagnosticados de EPOC (20 varones), con una edad media de 64 años. Se excluyó a los fumadores activos. El volumen espiratorio forzado en el primer segundo (FEV1) medio (± desviación estándar) fue un 43 ± 14% del teórico. Todos los pacientes tenían amplia experiencia en el uso de los dispositivos de inhalación. Se realizaron 3 combinaciones terapéuticas de forma aleatoria durante una semana: a) fluticasona (500 µg/12 h), salmeterol (50 µg/12 h) y placebo; b) fluticasona, tiotropio (18 µg/24 h) y placebo, y c) fluticasona, salmeterol y tiotropio. Al final de cada período se realizó una espirometría forzada entre las 8.30 y las 9.00 h, antes de la inhalación de la combinación y 2 h después de ésta. Durante toda la semana se recogió el pico de flujo matutino inmediatamente antes de la inhalación de los fármacos, dejando 48 h de lavado entre cada asociación. RESULTADOS: Todos los pacientes finalizaron el protocolo. No hubo diferencias significativas en el FEV1 tanto valle como postinhalación con salmeterol y tiotropio (FEV1 valle: 1,17 ± 0,55 frente a 1,19 ± 0,49 l; FEV1 postinhalación: 1,32 ± 0,65 frente a 1,29 ± 0,61 l). En todos los casos el FEV1 postinhalación fue significativamente superior al FEV1 valle. La combinación de fluticasona, salmeterol y tiotropio se mostró superior a las otras 2 tanto en el FEV1 valle como postinhalación (FEV1 valle: 1,32 ± 0,56 l, p < 0,03 en ambos casos; FEV1 postinhalación: 1,49 ± 0,68 l, p < 0,001 en los 2 casos). El pico de flujo también fue significativamente mayor con la combinación de los 2 broncodilatadores (345 frente a 291 l/m y 311 l/m, respectivamente; p < 0,04 en ambos casos). No hubo efectos secundarios reseñables. CONCLUSIONES: La asociación de salmeterol y tiotropio unidos a fluticasona en pacientes con EPOC de grado moderado- grave es más eficaz en términos de mejoría funcional respiratoria que cualquiera de los 2 broncodilatadores dados de forma aislada

OBJECTIVE: Bronchodilators are still the most effective drugs for controlling the symptoms of chronic obstructive pulmonary disease (COPD). Tiotropium bromide, a longacting anticholinergic drug, has recently been added to the therapeutic arsenal for the disease. To date, there have been no studies combining 2 long-acting bronchodilators. The aim of the present trial was to determine whether the combination of salmeterol and tiotropium improved lung function in COPD patients more than either of them alone. PATIENTS AND METHODS: Twenty-two patients (20 men) diagnosed with COPD, with a mean age of 64 years, were enrolled in this cross-over trial. Active smokers were excluded. Mean (SD) forced expiratory volume in 1 second (FEV1) was 43% (14%) of predicted. All patients were experienced in the use of inhalers. The following 3 therapeutic combinations were randomly assigned to be administered for a 1-week period: a) fluticasone (500 µg/12 h), salmeterol (50 µg/12 h) and placebo; b) fluticasone, tiotropium (18 µg/24 h), and placebo; and c) fluticasone, salmeterol, and tiotropium. At the end of each period, forced spirometry was performed before inhalation of the therapeutic combination (between 8:30 AM and 9:30 AM) and 2 hours after inhalation. Throughout the week, morning peak flow rates measured immediately before inhalation were recorded, and there was a 48-hour wash-out period between each therapeutic combination. RESULTS: All the patients completed the protocol. There were no significant differences in preinhalation or postinhalation FEV1 with salmeterol compared to tiotropium (preinhalation FEV1, 1.17 [0.55] L compared to 1.19 [0.49] L; postinhalation FEV1, 1.32 [0.65] L compared to 1.29 [0.61] L). In all cases postinhalation FEV1 was significantly higher than preinhalation FEV1. The combination of fluticasone, salmeterol, and tiotropium proved superior to the other 2 combinations with respect to both preinhalation FEV1 and postinhalation FEV1 (preinhalation FEV1, 1.32 [0.56] L, [P<.03 in both comparisons]; postinhalation FEV1, 1.49 [0.68] L [P<.001 in both comparisons]). Peak flow rate was also significantly higher with the combination of the 2 bronchodilators (345 L/min compared to 291 L/min and 311 mL, respectively [P <.04 in both cases]). There were no notable side effects. CONCLUSIONS: In terms of improvement in lung function, the combination of salmeterol and tiotropium together with fluticasone is more effective in patients with moderate-to-severe COPD than either of the 2 bronchodilators administered alone

[Clinical usefulness and cost-effectiveness of transbronchial needle aspiration for the diagnosis of mediastinal adenopathy]. / Utilidad clínica y coste-efectividad de la punción-aspiración transbronquial en el diagnóstico de adenopatías mediastínicas.

Transbronchial needle aspiration (TBNA) of mediastinal or hilar enlarged lymph nodes is a useful and safe technique. Nevertheless, its use has not become widespread, and the necessity of a specific training to obtain good results has been reported. In order to evaluate the clinical usefulness and cost-effectiveness of TBNA in inexperienced brochoscopists in this technique, a prospective study was conducted of this technique used in all patients with a chest CT with paratracheobronchial lymph nodes larger than 10 mm who had a fiberbronchoscopy ordered. TBNA was performed in 66 lymph node staging in 59 patients. In 76% of cases adequate specimens were obtaned, and a cytohistologic diagnosis was established in 59%. In 44% of patients, TBNA avoided other more invasive diagnostic procedures. Had TBNA not been performed, cost was estimated to have been at least five times higher. We conclude that TBNA could be a useful cost-effective technique in inexperienced teams.

Utilidad clínica y coste-efectividad de la punción-aspiración transbronquial en el diagnóstico de adenopatías mediastínicas / Clinical usefulness and cost-effectiveness of the transbronchial needle aspiration for the diagnosis of mediastinal lymph node enlargement

La punción-aspiración transbronquial (PATB) de adenopatías mediastínicas o hiliares es una técnica útil y segura. Sin embargo, su uso no se ha generalizado, describiéndose la necesidad de un entrenamiento específico para la obtención de buenos resultados. Con el objetivo de evaluar la utilidad clínica y el coste-efectividad de la PATB en broncoscopistas sin experiencia previa en la misma hemos realizado de forma prospectiva esta técnica a todos los pacientes con una tomografía axial computarizada (TAC) torácica con adenopatías paratraqueobronquiales mayores de 10 mm y a los que se les había solicitado una fibrobroncoscopia. Se realizó la PATB en 66 estaciones ganglionares de 59 pacientes. En el 76 por ciento de los casos se obtuvieron muestras adecuadas, pudiéndose realizar un diagnóstico citohistológico en el 59 por ciento. La PATB evitó en el 44 por ciento de los pacientes la realización de otros procedimientos más cruentos para el diagnóstico. De no haberse realizado la PATB estimamos que el coste hubiera sido como mínimo 5 veces superior. Concluimos que la PATB podría ser una técnica con una buena rentabilidad y coste-efectividad en equipos sin experiencia previa en la misma (AU)

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