NHANES III equations enhance early detection and mortality prediction of bronchiolitis obliterans syndrome after hematopoietic SCT.

Bronchiolitis obliterans syndrome (BOS) is a serious complication of chronic GVHD (cGVHD) following HSCT (hematopoietic SCT). The clinical diagnosis of BOS is based on pulmonary function test (PFT) abnormalities including: FEV1<75% predicted and obstructive FEV1/VC ratio, calculated using reference equations. We sought to determine if the frequency of clinical diagnoses and severity of BOS would be altered by using the recommended NHANES III vs older equations (Morris/Goldman/Bates, MGB) in 166 cGVHD patients, median age 48 (range: 12-67). We found that NHANES III equations significantly increased the prevalence of BOS, with an additional 11% (18/166) meeting diagnostic criteria by revealing low FEV1 (<75%) (P<0.0001), and six additional patients by obstructive ratio (vs MBG). Collectively, this led to an increase of BOS incidence from 17 (29/166) to 29% (41/166). For patients with severe BOS, (FEV1<35%), NHANES III equations correctly predicted death 71.4% vs 50% using MGB. In conclusion, the use of NHANES III equations markedly increases the proportion of cases meeting diagnostic criteria for BOS and improves prediction of survival.

Spirometry in surgery for anterior mediastinal masses.

STUDY OBJECTIVES: To identify the impact of upright and supine spirometry (USS) on the choice of anesthesia and outcomes in patients undergoing surgery for anterior mediastinal masses (AMMs). DESIGN: Retrospective cohort study. SETTING: A referral, tertiary-care, military medical center. PATIENTS: We reviewed the records of all patients who underwent surgery for AMMs between June 1994 and December 2000 at Walter Reed Army Medical Center. Patients aged > or = 18 years who had "anterior mediastinal mass" listed as the preoperative diagnosis, which had been confirmed by a preoperative CT scan, and who had available preoperative spirometry data were included in our analysis. In cases in which surgery was performed more than once on the same individual, only data from the first operation were evaluated. MEASUREMENTS: Patient demographics, the results of pulmonary function testing, perioperative complications, type of anesthesia, type of surgery, and pathology were used in the evaluation. RESULTS: Thirty-seven patients (median age, 31 years; age range, 19 to 86 years) were included in the final analysis. There were 24 men and 13 women in this group. The mean (+/- SD) seated FVC and FEV(1) values for the group were 4.02 +/- 0.75 L (90.7 +/- 13.3% predicted) and 3.22 +/- 0.56 L 89.6 +/- 14.2% predicted. Twelve patients (32.4%) had USS ordered, and 10 patients (27.0%) had USS performed. USS was ordered significantly more frequently in younger and symptomatic patients (p = 0.022 and p = 0.005, respectively). Spirometry suggestive of possible upper airway obstruction was found in four patients. However, general anesthesia was used in all four patients without complications. Only two patients suffered perioperative complications. One of these patients had normal USS values but underwent surgery under local anesthesia nonetheless. CONCLUSIONS: The recommendation to perform USS prior to surgery on AMMs is based on anecdotal data. Our study found that the incidence of perioperative complications in surgery for AMMs is low. We also found that USS is not ordered in all patients preoperatively and that the results do not always alter the anesthetic technique when abnormal. One patient who experienced a perioperative complication had normal USS values. Larger studies are necessary to further evaluate the utility of USS in surgery for AMMs.

Endobronchial involvement and airway hyperreactivity in patients with sarcoidosis.

STUDY OBJECTIVE: To determine the relationship between airway hyperreactivity (AHR) and endobronchial involvement in patients with sarcoidosis. DESIGN: Prospective series of consecutive patients. SETTING: Pulmonary clinic of a military, tertiary-care teaching hospital. PATIENTS: Patients with newly diagnosed sarcoidosis. INTERVENTIONS: All patients undergoing bronchoscopy for the diagnosis of sarcoidosis underwent an evaluation that included history, physical examination, chest radiography, and spirometry. Bronchoprovocation testing was done using methacholine. During bronchoscopy, six endobronchial biopsy (EBB) specimens were obtained. In patients with abnormal-appearing airways, four specimens were obtained from abnormal areas and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy specimen was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. Only patients with histologic confirmation of sarcoidosis were included in the data analysis. MEASUREMENTS AND RESULTS: The study cohort included 42 patients (57.1% were men, 61.9% were African American, and mean age [+/- SD] was 37.3 +/- 6.6 years). AHR was present in nine patients (21.4%), while EBB revealed nonnecrotizing granulomas in 57.1% of patients. All patients with AHR had positive EBB findings compared to 45.5% of individuals without AHR (p = 0.005). There was a trend toward lower lung volumes and flow rates in patients with AHR, but this did not reach statistical significance. The mean serum angiotensin-converting enzyme level was higher in patients with AHR (79.3 +/- 53.9 IU/L vs 37.5 +/- 26.7 IU/L, p = 0.05). No other clinical variable correlated with the presence of AHR. CONCLUSIONS: AHR may be seen in patients with sarcoidosis. Endobronchial involvement significantly increases the risk for AHR and may play a role in the development of AHR in patients with sarcoidosis. Other clinical factors are not clearly associated with AHR in patients with sarcoidosis.

Endobronchial biopsy for sarcoidosis: a prospective study.

STUDY OBJECTIVES: To determine the yield of endobronchial biopsy (EBB) for suspected sarcoidosis, and to evaluate if EBB increases the diagnostic value of fiberoptic bronchoscopy (FOB) when added to transbronchial biopsy (TBB). DESIGN: Prospective study of consecutive patients. SETTING: Pulmonary clinic of a tertiary-care, academic medical center. PATIENTS: Patients consecutively referred for suspected pulmonary sarcoidosis. INTERVENTIONS: All patients having FOB performed underwent an evaluation that included history, physical examination, a chest radiograph, and spirometry. During FOB, airway appearance was recorded and both TBB and EBB were performed in a standardized fashion. Six TBB specimens were obtained, as were six EBB samples. For patients with abnormal-appearing airways, four specimens were obtained from the abnormal-appearing airways and two specimens were obtained from the main carina. In patients with normal-appearing airways, four specimens were obtained from a secondary carina and two specimens were obtained from the main carina. A biopsy finding was considered positive if it demonstrated nonnecrotizing granulomas with special stains that were negative for fungal and mycobacterial organisms. MEASUREMENTS AND RESULTS: The study cohort included 34 subjects (mean +/- SD age, 37.9 +/- 6.8 years; 58.8% were male; 64.7% were African American). EBB findings were positive in 61.8% of patients, while TBB showed nonnecrotizing granulomas in 58.8% of subjects. The addition of EBB increased the yield of FOB by 20.6%. Although EBB findings were more frequently positive in abnormal-appearing airways (p = 0.014), EBB provided diagnostic tissue in 30.0% of patients with normal-appearing endobronchial mucosa. There were no complications resulting from the addition of EBB to TBB. CONCLUSIONS: Endobronchial involvement is common in sarcoidosis. EBB has a yield comparable to TBB and can safely increase the diagnostic value of FOB. Pulmonologists should consider routinely performing EBB in cases of suspected sarcoidosis.

Circulating D dimer in patients with sarcoidosis.

STUDY OBJECTIVES: To determine the relationship between D dimer (DD) status and markers of disease activity in patients with sarcoidosis. DESIGN: Prospective, observational analysis. SETTING: Pulmonary clinic of a tertiary care, university-affiliated hospital. PATIENTS: Consecutive individuals with newly diagnosed sarcoidosis. INTERVENTION: Determination of serum DD. MEASUREMENTS AND RESULTS: The study cohort included 28 subjects, and DD was present in 39.3%. DD status correlated with the radiographic stage of disease (p = 0. 035), diffusing capacity of the lung for carbon monoxide (p = 0.026), serum angiotensin-converting enzyme level (p = 0.006), and the presence of dyspnea (p = 0.034). Patients with circulating DD were 3. 8 times more likely to have radiographic evidence of interstitial involvement. DD was not associated with either FVC or the FEV(1). CONCLUSIONS: DD is frequently positive in patients with sarcoidosis. DD is associated with disease activity as measured by radiograph, pulmonary function tests, and serum markers of inflammation.

Diagnosing and monitoring the clinical course of chronic obstructive pulmonary disease.

COPD is an extremely common, chronic disorder characterized by a reduction in airflow after the administration of an inhaled bronchodilator as measured by the FEV1. The diagnosis is suspected in patients with a history of several decades of cigarette smoking who present with nonspecific respiratory symptoms. The diagnosis is established by simple forced expiratory spirometry. Baseline evaluation usually includes a chest radiograph and some assessment of functional capacity, either by history or with some form of exercise testing. In patients whose initial FEV1 is more severely reduced or who have significant dyspnea, an arterial blood gas is indicated at baseline. Dyspnea, hypoxemia, or hypercarbia that is out of proportion to the measured FEV1, at either presentation or follow-up, should prompt a thorough evaluation for complicating conditions. There are important roles in health care delivery and chronic disease management strategies for RCPs, primary care providers, and specialty trained pulmonary physicians. The need for repeated, extensive, or expensive testing will be largely driven by patients symptoms but disease monitoring with periodic assessments of dyspnea, functional capacity, and spirometry can be performed without great expense.

Delivery of high concentrations of inspired oxygen via Tusk mask.

OBJECTIVES: Nonrebreather face masks (NRM) are frequently used in patients with respiratory distress and profound hypoxemia. A simpler modification to the partial rebreather face mask, using only two pieces of respiratory tubing or "tusks," has also been shown to increase FiO2 compared with the NRM in five normal subjects. Clinically, we have observed this modification to further increase PaO2 in critically ill patients already using the NRM in the intensive care unit. This study was designed to compare the Tusk mask with the NRM in both a larger group of normal subjects and in patients with underlying lung disease. DESIGN: Prospective, randomized, crossover study. SETTING: A university teaching hospital and tertiary care referral center. SUBJECTS: Sixteen normal subjects (11 male and 5 female; age 30.4+/-6.8 [SD] yrs) and seven patients with interstitial lung disease (ILD) (3 male and 4 female; age 68.1+/-11.9 yrs). INTERVENTIONS: Subjects and patients served as their own controls and were randomized to wear either the NRM or Tusk mask for a 30-min period. After a 60-min washout period, the other mask was applied. MEASUREMENTS AND MAIN RESULTS: Arterial blood gas measurements were performed immediately before and at the end of each 30-min test period. Respiratory synchronization during the study period was achieved, using a metronome. In the normal subjects, PaO2 using the NRM and Tusk masks increased 290.0+/-57.1 torr (38.6+/-7.6 kPa) and 330.0+/-68.9 torr (44.0 +/-9.2 kPa), respectively (p=.032). PaO2 increased 293.4+/-38.0 torr (39.1+/-5.1 kPa) with the NRM and 378.4+/-61.7 torr (50.4+/-8.2 kPa) with the tusk mask (p=.001) in the patients with ILD. There was no statistically significant change seen in mean PaCO2 with either mask in either group. The mean PaO2 returned to within 6% of baseline in both groups after the washout period. CONCLUSIONS: Both normal subjects and patients with compromised pulmonary function achieved a higher PaO2 using a Tusk mask than when using the conventional NRM, at the same oxygen flow rate. Patients with hypoxemia may obtain lifesaving benefit from the additional concentration of oxygen delivered via the Tusk mask.

Necessity of routine chest roentgenography after thoracentesis.

OBJECTIVE: To determine the necessity of posteroanterior chest roentgenography for the identification of pneumothorax and other complications after thoracentesis. DESIGN: Prospective cohort study. SETTING: Tertiary care teaching hospital. PATIENTS: 67 men and 43 women (mean age +/- SD, 62.4 +/- 13.2 years). Exclusion criteria included age younger than 18 years, concurrent pleural biopsy, ultrasound guidance, and use of mechanical ventilation. MEASUREMENTS: 174 thoracenteses done between March 1991 and June 1993. RESULTS: 2 hemothoraces (1.2%) occurred, and 8 patients had a total of 9 pneumothoraces (5.2%). The roentgenograms obtained immediately after the procedures identified 8 pneumothoraces; the other pneumothorax was seen incidentally on a delayed roentgenogram obtained 3 days later. Pneumothorax was suspected in 5 of the 8 cases, and tube thoracostomy was done in 4 of these 5 cases. Patients with unsuspected pneumothorax identified on the roentgenogram obtained immediately after the procedure did not receive treatment for their pneumothoraces. Univariate analysis showed that the variables that correlated significantly with pneumothorax were aspiration of air during the procedure (relative risk ratio, 12.3; 95% CI, 3.7 to 41.4), number of passes with the thoracentesis needle (relative risk ratio, 6.1; CI, 1.6 to 23.3), history of thoracic radiation therapy (relative risk ratio, 10.5; CI, 2.5 to 44.4), and operator suspicion of pneumothorax (relative risk ratio, 25.9; CI, 8.6 to 78.5). CONCLUSION: Among hospitalized patients with pleural effusions, we identified subgroup of patients in whom the risk for pneumothorax is low enough (approximately 1%) with sufficiently minimal clinical consequences to justify the avoidance of about 60% of chest roentgenograms obtained after thoracentesis. These patients are clinically stable, have not previously received chest irradiation, had only one pass at thoracentesis attempted without the aspiration of any air, and give no other indication of pneumothorax.

Evaluation of internists' spirometric interpretations.

BACKGROUND: Correct interpretation of screening spirometry results is essential in making accurate clinical diagnoses and directing subsequent pulmonary evaluation. The general internist is largely responsible for interpreting screening spirometric tests at community hospitals. However, reports of new guidelines for screening spirometry are infrequently published in the general internal medicine literature. This can lead to incorrect interpretations. We sought to evaluate whether spirometric interpretations by a group of practicing general internists differed from those of two board-certified pulmonologists using guidelines published by the American Thoracic Society (ATS). METHODS: As part of a Continuous Quality Improvement project, all available screening spirometric tests over a 3-month period at two area community hospitals were reviewed. Only those performed on individuals age 18 or older were included in the analysis. Comparison was made between the interpretations of staff internists and those of two pulmonologists, who were blinded to the results of all other interpretations. We analyzed 110 screening spirometric tests from 84 males and 26 females. The patients ranged in age from 18 to 77 (mean 41 +/- 13 years of age). RESULTS: There was 97% concordance between the two pulmonologists' interpretations. In three cases, interpretations of only one pulmonologist agreed with those of the internists. The internists and both pulmonologists agreed in 73 cases. The majority of spirometric results in this subgroup were normal (n = 54). Both pulmonologists disagreed with internists' nomenclature in five cases. There was complete disagreement between the pulmonologists and the internists in the other 29 cases. Using the pulmonologists' interpretations as the "gold standard," the sensitivity (the internists' ability to correctly identify abnormal spirometric results) was 58.8% (95% confidence interval [CI] 42.2%, 73.3%), the specificity was 81.8% (95% CI 70.0%, 89.8%), the positive predictive value was 66.7% (95% CI 49.0%, 80.9%), and the negative predictive value was 76.1% (95% CI 64.3%, 85.0%). The most common inaccurate interpretations made by internists were "small airways disease" when spirometric results were normal (n = 8); "normal" when a restrictive pattern was present (n = 6), and "normal" when an abnormal flow-volume loop suggesting possible upper airway obstruction was present (n = 5). CONCLUSIONS: The spirometric interpretations of a group of general internists differed significantly from those of two board-certified pulmonologists using published guidelines in approximately one third of cases. This may be because subspecialty guidelines are infrequently published in the general internal medicine literature. We believe that wider dissemination of these interpretative guidelines and ongoing physician education would improve general internists' ability to identify patients who require further pulmonary evaluation.

Adherence to established guidelines for preoperative pulmonary function testing.

Guidelines for ordering preoperative spirometry have been proposed by GM Tisi (1979) and more recently by the American College of Physicians (ACP). Requests for preoperative spirometries represent a significant portion of all requests for screening spirometry at our institution and utilize significant man-hours of technician time. We determined the percentage of these requests that did not meet the ACP guidelines and characterized why these requests were being generated. We sampled 441 screening spirometries performed by the Walter Reed Pulmonary Function Laboratory over a 4-week period. One hundred thirty-eight (31%) of these were done preoperatively and complete data were available in 135 cases. Patients in the analyzed group had a mean age of 59 years (+/- 14 years), ranging from 20 to 84 years of age. Fifty-two (39%) requests did not meet ACP guidelines. Most of these requests were associated with either normal spirometry (n = 34) or only mild spirometric abnormalities (n = 14). Spirometry revealed severe obstruction in only one case when the request was not indicated. No cases of moderate obstruction, severe restrictive pattern, or possible upper airway obstruction were found in the group of requests in which spirometry was not indicated. Of the requests that did not meet ACP guidelines, 21 met Tisi's broader guidelines. Most of these requests were found exclusively in patients older than 70 years of age (n = 13) and the morbidly obese (n = 4). Of the 31 studies that did not meet either set of guidelines, 25 occurred in asymptomatic, current, or prior smokers. In conclusion, during a 4-week study period at our institution, 39% of preoperative spirometry requests did not meet ACP guidelines. Most of the patients had been referred because of age greater than 70 years, morbid obesity, and a current/prior history of smoking. However, the literature does not support obtaining preoperative spirometry in such patients except for those undergoing only lung resection. We recommend stricter adherence to the ACP guidelines as a means of decreasing the number and cost of unnecessary spirometries being performed.

Noninvasive monitoring.

Noninvasive monitors are finding increased use in the intensive care unit both as labor-saving tools and as a means to reduce complications associated with invasive techniques. The current technology allows for the replacement of a number of invasive devices with a noninvasive counterpart capable of providing similar information. The potential reduction in morbidity and mortality realized with a greater reliance on noninvasive monitors should result in widespread application of these modalities.

Maximum voluntary ventilation. Spirometric determinants in chronic obstructive pulmonary disease patients and normal subjects.

The 12-s maximum voluntary ventilation (MVV) provides an estimate of the ventilatory reserves available to meet the physiologic demands of exercise. Earlier studies established a general relationship between MVV and FEV1. We hypothesized that the resting maximum inspiratory flow rate (MIFR) also serves as a clinically useful predictor of the MVV. A total of 105 subjects, 45 women and 60 men (age 57 +/- 5 yr, mean +/- SD), with expiratory impairment categories of severe (n = 26), moderate (n = 22), mild (n = 18), and normal (n = 39) based on FEV1 (percentage of predicted), comprised the study samples. The ratio MVV/FEV1 averaged 41 +/- 7 overall. The FEV1 correlated with MVV in normal subjects (p < 0.05, r2 = 0.642) and patients (p < 0.05, r2 = 0.787) better than MIFR (p < 0.05, r2 > or = 0.480). MIFR joined with FEV1 in multiple linear regression to significantly improve the description of MVV:MVV L/min = 30.77FEV1 (L) + 5.94MIFR (L/s) - 4.77 (n = 105; p < 0.05, r2 = 0.849). The 95% confidence limits for MVV varied from 90 to 110% of predicted from the equation for this sample. The factors sex and impairment category did not reduce the unexplained variability in MVV after inclusion of FEV1 and MIFR as covariates in ANOVA (p > 0.05). Addition of MIFR to the model with FEV1 produced greater improvement in r2 than PImax. We conclude that MIFR, although secondary in importance to FEV1, is a significant determinant of MVV in patients with COPD and normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of bedside plating of semiquantitative cultures for diagnosis of central venous catheter-related infections in ICU patients.

We compared semiquantitative central venous catheter tip cultures plated at the bedside with those cultured in the laboratory, to determine if bedside plating provides a significantly better yield. Paired segments of 197 catheter tips from 92 surgical and medical ICU patients were evaluated prospectively. A total of 31 catheter tip cultures were positive for > or = 15 organisms per agar plate, with 10 of these being simultaneously positive at the bedside and in the laboratory. Cultures were exclusively positive in 18 cases plated immediately at the bedside, whereas laboratory plating resulted in only 3 exclusively positive cases. This discrepancy was statistically significant (p < 0.005). Compared with bedside plating, the sensitivity and specificity of sending catheters to the laboratory were 36 percent and 98 percent, respectively. These results indicate that the practice of sending central venous catheter tips to the laboratory for routine culture should be reconsidered in favor of bedside plating.

Churg-Strauss syndrome.

A 62-year-old woman who had a history of asthma and allergic rhinitis developed bilateral pulmonary infiltrates and marked eosinophilia. A transbronchial biopsy specimen did not help clarify the diagnosis. She later developed erythematous nodules on her feet; results of a biopsy specimen revealed necrotizing extravascular granulomas and marked infiltration of the dermis with eosinophils consistent with a diagnosis of Churg-Strauss syndrome. Skin manifestations are often nonspecific in this syndrome and occur in approximately two thirds of cases.

Hepatic and intestinal contribution of two forms of apolipoprotein B to plasma lipoprotein fractions in the rat.

The in vivo incorporation of labeled amino acids into two forms of apolipoprotein B of nascent hepatic, nascent intestinal, and plasma lipoproteins was studied. Using SDS-gel filtration column chromatography rat apolipoprotein B was separated into two proteins of higher (apo Bh) and of lower (apo Bl) molecular size and the incorporation of label into each was measured. When livers isolated from fed rats were perfused with 3H-labeled amino acids, radioactivity was incorporated into both forms of apo B of the d less than 1.060 fractions (very low (VLDL), intermediate (IDL), and low (LDL) density lipoproteins) with a labeling ratio of apo Bl to apo Bh of 0.8. When mesenteric lymph was collected from corn oil fed rats intraduodenally injected with 3H-labeled amino acids, radioactivity was mainly incorporated into apo Bl of chylomicrons and VLDL with apo Bl to apo Bh labeling ratios of 14 and 44, respectively. Plasma was isolated 2 h after intraperitoneal injection of 3H-labeled amino acids into chow fed rats and lipoproteins were isolated by sequential density ultracentrifugation. The labeling ratio of apo Bl and apo Bh decreased from 4.2 in VLDL to 0.5 in LDL indicating a progressive enrichment of apo Bh in the LDL fraction. High density lipoproteins (HDL) contained less than 4% of the total labeled apo B and was enriched in apo Bl. The results of this study indicate that the liver synthesizes both forms of apo B while the intestine synthesizes almost entirely apo Bl. Since both apo B proteins are secreted primarily by the liver into VLDL, the results are consistent with preferential removal of apo Bl during triglyceride-rich lipoprotein catabolism and entry of hepatically derived apo Bh into LDL.