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.

Acute pancreatitis in patients with hemorrhagic fever with renal syndrome.

The objective of this study was to determine the prevalence and clinical significance of acute pancreatitis in patients in whom hemorrhagic fever with renal syndrome (HFRS) has been diagnosed. We retrospectively reviewed all patients with a diagnosis of HFRS at our institution from 1994 to 1998. The review included medical records, laboratory results, radiologic examinations, and one autopsy report. From 1994 to 1998, 13 patients received diagnoses of HFRS that were confirmed by serology. In 9 patients (69%), serum amylase, serum lipase, or both were assessed during hospitalization. Seven (78%) of the 9 patients had pancreatitis. Four (57%) of these 7 patients with HFRS and pancreatitis had associated pulmonary edema, and 1 patient had rhabdomyolysis. In our small retrospective case series, acute pancreatitis in patients with HFRS was much more common than previously recognized. Patients with HFRS and pancreatitis had increased morbidity. However, the treatment for the associated pancreatitis was conservative.

Lack of predictive value of the Epworth Sleepiness Scale in patients after uvulopalatopharyngoplasty.

The Epworth Sleepiness Scale (ESS) has been recognized as a valid measure of sleep propensity. Statistically significant correlations between ESS scores, the respiratory disturbance index (RDI), and the lowest arterial oxygen saturation (LSAT) have been described in patients with surgically untreated obstructive sleep apnea (OSA). We investigated whether the same relationships hold true after uvulopalatopharyngoplasty (UPPP). Forty-two adults with documented OSA treated by UPPP were reevaluated with the ESS questionnaire and 8-hour diagnostic nocturnal polysomnography (nPSG). We found no significant correlation between the ESS scores and the RDI or LSAT in patients after UPPP. Because postoperative ESS scores do not correlate with the RDI or LSAT, we conclude that the ESS is not a reliable surrogate for nPSG testing.

Improvement in hypoxemia at 4600 meters of simulated altitude with carbohydrate ingestion.

BACKGROUND: Carbohydrate ingestion increases the relative production of carbon dioxide which results in an increase in ventilation in normal individuals. An increase in ventilation at altitude can result in improvement of altitude-induced hypoxemia. HYPOTHESIS: Carbohydrate ingestion will increase the arterial blood oxygen tension and oxyhemoglobin saturation during acute high altitude simulation. METHODS: There were 15 healthy volunteers, aged 18-33 yr, who were given a 4 kcal x kg(-1) oral carbohydrate beverage administered 2.5 h into an exposure to 15,000 ft (4600 m) of simulated altitude (5.5 h after the last meal). Altitude was simulated by having subjects breath a 12% oxygen/balance nitrogen mixture while remaining at sea level. Arterial blood gas samples were drawn at baseline and at regular intervals up to 210 min after carbohydrate ingestion. Subjects were evaluated for AMS by use of the Environmental Symptoms Questionnaire (ESQ) and a weighted average of cerebral symptom score (AMS-C). RESULTS: Baseline PaO2 increased significantly (p < 0.01) from 43.0 +/- 3.0 mmHg at 4600 m before carbohydrate ingestion to 46.8 +/- 6.2 mmHg at 60 min after carbohydrate ingestion. Arterial oxygen saturation rose significantly (p < 0.01) from a baseline of 79.5% +/- 5.1 to 83.8% +/- 6.42 at 60 min. CONCLUSIONS: Carbohydrate consumption significantly increased oxygen tension and oxyhemoglobin saturation in arterial blood of normal subjects during simulated altitude. Effects reached statistical significance across all subjects at 60 min. There was no significant difference in arterial oxygen levels or arterial oxygen saturation in subjects who developed AMS vs. those who did not develop AMS.

Serum angiotensin converting enzyme does not correlate with radiographic stage at initial diagnosis of sarcoidosis.

Serum levels of angiotension converting enzyme (ACE) are elevated in many patients who suffer from sarcoidosis. Few studies have correlated ACE levels at diagnosis with the radiographic stage of the disease. The present authors reviewed the charts of all patients who had the diagnosis of sarcoidosis made between 1990 and 1995, and correlated ACE level at diagnosis with radiographic stage. Only patients with biopsy-proven sarcoid were included. One hundred and sixteen cases were identified, and complete data were available for 104 individuals. Serum ACE levels were increased in approximately 63.5% of the study population. The relationships between both stage and ACE level, and stage and percentage of individuals with elevated ACE levels within that stage were not statistically significant (P > 0.05). This large, retrospective study of patients with histologic evidence of sarcoidosis demonstrated no association between serum ACE level and radiographic stage.

Do-not-resuscitate decisions in the medical ICU: comparing physician and nurse opinions.

STUDY OBJECTIVE: To determine how soon after admission to a medical ICU physicians and nurses decide that attempts at resuscitation are inappropriate and how frequently physicians and nurses disagree about do-not-resuscitate (DNR) decisions. DESIGN: Prospective, opinion survey of care providers. SETTING: Ten-bed adult medical ICU in a university-affiliated tertiary care referral hospital. PATIENTS: Consecutive adult medical ICU admissions. INTERVENTIONS: Over 10 months, physicians and nurses were surveyed independently every day regarding their opinions about DNR issues on each patient in the ICU. MEASUREMENTS: ICU day when DNR order was deemed appropriate by either physicians or nurses. RESULTS: Of 368 consecutive admissions, 84 (23%) patients were designated DNR during their ICU stay. In 6 of these 84 cases (7%), the responsible nurse did not agree that DNR orders were appropriate. In the remaining 78 patients designated DNR, the median time for physicians to recommend DNR (median, 1 day; range, 0 to 22 days) was not significantly different from the median time for nurses (median, 1 day; range, 0 to 13 days); (p=0.45). For the 284 patients not designated DNR, physicians and nurses both believed DNR was appropriate in 14 cases (5%), but a DNR order was not written five times (2%) because there was not time to do so and nine times (3%) because patient or family did not concur. Physicians and nurses disagreed about a DNR recommendation in 33 of the 284 patients not designated DNR (12%). Physicians were more likely to believe that DNR was appropriate than were nurses (p<0.0005), with physicians alone recommending DNR 29 times (10%) and nurses alone favoring DNR in four cases (1%). CONCLUSIONS: At our institution, recognition of DNR appropriateness by nurses and physicians occurs over a similar time frame. However, physicians are more likely to recommend DNR in cases of disagreement between nurses and physicians.

Endobronchial disease and racial differences in pulmonary sarcoidosis.

In a retrospective review of 7 years of Walter Reed Army Medical Center fiberoptic bronchoscopy records, 154 patients with biopsy specimen proved (122) and clinically diagnosed (32) sarcoidosis were identified. Endobronchial mucosal appearance was normal in only 70 (45%). Abnormal mucosal findings included erythema (29 patients), nodules (13), plaques (13), and cobblestoning (29). Fifty-nine patients were evaluated with endobronchial biopsies (EBBX), and non-necrotizing granulomata diagnostic of sarcoidosis were found in 42 (71%). The diagnostic yield from endobronchial biopsies was similar regardless of the type of mucosal abnormality. EBBX specimens were diagnostic in 85% of black patients and 38% of white patients (p = 0.00081), but diagnostic yield did not correlate with patient's sex, symptoms, radiographic stage of disease, or extent of physiologic abnormalities. Four patients with normal-appearing bronchial mucosa underwent EBBX, and sarcoidosis was diagnosed in two. Transbronchial lung biopsy (TBBX) specimens were diagnostic of sarcoidosis in 61 of 82 (74%) black and 28 of 56 (50%) white patients (p = 0.0038). We conclude that the bronchial mucosa appears abnormal in the majority (55%) of patients with sarcoidosis. EBBX specimens will diagnose sarcoidosis in a high percentage of such patients and should be performed routinely. EBBX may be preferable to TBBX because of its greater safety profile. In our patients, the yield of both EBBX and TBBX was significantly greater in African-Americans than white Americans.

Postoperative pulmonary changes after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has been widely used in recent years because of short postoperative hospital stays and low morbidity. In this study, 24 patients were prospectively evaluated with preoperative and postoperative spirometry, arterial blood gas determinations, and chest radiographs to quantitate the magnitude of postoperative pulmonary changes after LC. Statistically significant reductions were noted in forced vital capacity (FVC) (mean decrease, 810 mL) and forced expired volume in 1 second (FEV1) (mean decrease, 420 mL). Clinically important changes in arterial blood gas values did not occur. Of 20 postoperative chest films, 7 showed the development of atelectasis or effusion and 9 showed persistence of subdiaphragmatic free air 24 hours after LC. In summary, LC caused mean decreases of 23% in FVC and 16% in FEV1 24 hours after surgery. The physiologic derangements that follow LC are sufficiently small that all but the most severely impaired patients with pulmonary disease should be able to tolerate this operation.

Pulse oximetry correction for smoking exposure.

Pulse oximetry oxygen saturation (SpO2) does not distinguish carboxyhemoglobin (COHb) from oxyhemoglobin (O2Hb), giving a false impression of the apparent degree of oxyhemoglobin saturation in smokers who have elevated levels of COHb. We questioned whether accounting for smoking exposure history could improve description of pulse oximetry by correcting for COHb levels. We evaluated smoking history and %SpO2 as predictors of %O2Hb and %COHb by CO-oximetry of arterial blood in 18 actively smoking and 18 age-matched nonsmoking patients in a clinical pilot study. The difference between %SpO2 and %O2Hb was significantly greater (p < 0.001) in the smokers (5.6 +/- 3.1) than the nonsmokers (2.1 +/- 2.1). This difference correlated with %COHb (rp = 0.789; p < 0.001) and the smoking exposure score (SES, rp = 0.621; p < 0.001), a six-point index we developed based on whether patients were active smokers, refrained from smoking prior to testing, or were exposed to passive smoking in the home or workplace. The following formula summarizes the correction: %O2Hb = 0.882[%SpO2] - 0.968[SES] + 9.245 (rp = 0.841; SES = 2.478; p < 0.001). This pilot study suggests that smoking exposure history correlates with COHb levels and that correction for smoking exposure improves the accuracy of pulse oximetry.

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.

Fiberoptic bronchoscopy in the evaluation of newly diagnosed esophageal carcinoma.

To determine the diagnostic utility of fiberoptic bronchoscopy (FB) in the evaluation of patients with newly diagnosed esophageal carcinoma (EC) and whether FB findings impact therapy and survival, we retrospectively reviewed 2,832 FB records (1984 through 1992). Twenty-two cases were identified in which FB was performed to evaluate pulmonary involvement in patients with newly diagnosed EC. Two cases were eliminated due to data unavailability. Seventeen of 20 patients had no pulmonary symptoms and most of them (15/17) had normal chest radiographs. All three patients with pulmonary symptoms (cough, hemoptysis, dyspnea) had significant radiographic abnormalities. In the asymptomatic group, FB findings were normal in nine, showed extrinsic compression of the trachea and/or bronchi in seven, and demonstrated a submucosal tumor nodule in one. The pathologic diagnosis of malignant airway involvement was not made in any asymptomatic patient. In the three symptomatic patients, extensive endobronchial abnormalities were present. Therapy with surgery, radiation, and/or chemotherapy did not differ among patients with extrinsic compression compared to patients with normal FB. Average survival in the patients with normal endobronchial anatomy was 20.5 months, in the group with extrinsic compression 12.2 months, and in the group with marked endobronchial abnormalities, less than 1 month. Statistical analysis of our findings suggest that FB is a low-yield procedure in the evaluation of patients with EC unless pulmonary symptoms of cough and/or hemoptysis or chest radiographic abnormalities are present.

Small volume bronchoalveolar lavage used in diagnosing Pneumocystis carinii pneumonia in HIV-infected patients.

To determine the volume of bronchoalveolar lavage (BAL) fluid necessary to diagnose Pneumocystis carinii pneumonia (PCP) in immunocompromised patients, specimens from 25 patients were evaluated. Twenty-one patients were HIV infected. BAL was performed using three to four 60-mL aliquots of room temperature, sterile, saline solution. Each syringe of BAL effluent was numbered and its volume was measured. Immunofluorescent stains were performed on about 8-mL aliquots of the initial, final, and aggregate BAL specimens, and a modified Giemsa stain was also performed on a 0.4-mL aliquot of the aggregate specimen. Of 25 patients, Pneumocystis carinii organisms were identified in 9 with HIV infection, in whom all BAL specimens were positive with both immunofluorescence and Giemsa stains. In 16 patients, BAL specimens were negative for P carinii on both immunofluorescent and modified Giemsa testing. Both staining methods were 100% specific (95% confidence interval [CI], 83 to 100%) and 100% sensitive (95% CI, 72 to 100%). The volume of BAL effluent in the initial specimens positive for P carinii ranged from 15 to 25 mL. We conclude that in this small group of patients, PCP was accurately diagnosed from a single 60-mL BAL specimen stained with immunofluorescence methods.

Exploratory thoracotomy for nonresectable lung cancer.

We sought to evaluate the effect of new diagnostic modalities on patients explored surgically for inoperable lung cancer. From July 1983 to February 1992, 335 patients underwent thoracotomy for lung cancer. Thirty-three of the 35 patients with nonresectable disease had sufficient data for analysis and underwent chest radiography (CXR), CT scan, and bronchoscopy. The study was terminated when video-assisted thoracoscopy (VAT) was introduced at the institution. Causes of nonresectability included significant N2 disease not diagnosed preoperatively (n = 11), tumor invasion of contiguous mediastinal structures (n = 8), and insufficient pulmonary function (n = 4). Four patients were left with unresected disease because of thoracic metastasis. Two patients had technically unresectable disease; three patients were explored surgically because diagnoses could be obtained by no other means. One patient was found to have small cell cancer. Data analysis demonstrated that 19 of 33 thoracotomies could potentially have been avoided or resulted in resection with current techniques. Refinement of imaging criteria, a judicious surgical approach to N2 disease, and VAT may significantly reduce thoracotomies for nonresectable lung cancer.

Sarcoidosis complicated by chylothorax.

Chylothorax is a rare complication of sarcoidosis; only one well-documented case has been described previously. Before chylothorax is diagnosed in a patient with sarcoidosis, infection and malignancy need to be aggressively excluded as possible diagnoses. We report the case of a 34-year-old black woman with sarcoidosis confirmed by lung, pleural, and mediastinal lymph node biopsies whose clinical course was complicated by chylothorax. Oral corticosteroid treatment resulted in prompt resolution of the chylothorax.