U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive…

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Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management.

Respiration. 2010;80(1):38-58

Authors: Sakr L, Dutau H

Hemoptysis is frequently encountered in clinical practice, and may be the presenting symptom of a number of diseases. Although massive hemoptysis accounts for only 5-15% of episodes, it should always be considered as a life-threatening condition that warrants effective assessment and management. In this article, we review the literature with regard to the definition, etiology, epidemiology, pathophysiology, diagnosis and treatment of massive hemoptysis, with special emphasis on the role of bronchoscopy as a diagnostic and therapeutic tool. We briefly present the circumstances under which the use of rigid bronchoscopy should be preferred for controlling massive bleeding. Moreover, we address the crucial importance of multidisciplinary collaboration by illustrating the roles of endovascular therapy and surgery in the optimal management of massive hemoptysis.

PMID: 20090288 [PubMed - indexed for MEDLINE]

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Vibration response imaging in the detection of pleural effusions: a feasibility study.

Respiration. 2009;77(2):166-72

Authors: Anantham D, Herth FJ, Majid A, Michaud G, Ernst A

BACKGROUND: Computerized analysis of the regional distribution of breath sound intensity during respiration has generated interest as a possible diagnostic modality. OBJECTIVES: We hypothesized that pleural effusions would create a dependent region of absent breath sounds and thus vibration response imaging (VRI) could be used in the detection of such pleural effusions. METHODS: A prospective, single-blinded and open-labeled trial was carried out, and VRI recordings were compared to upright chest X-rays, bedside ultrasound examinations and volume of fluid drained via thoracentesis. VRI images were interpreted by a physician who was blinded to the patients’ clinical history, physical examination and diagnostic tests. Quantitative assessment of pleural effusion size in the VRI images was performed by ImageJ software and an automatic pixel count analysis. RESULTS: VRI recordings were performed on 57 consecutive patients and correctly predicted the diagnosis in 45 cases (45/56, 80%) as compared to chest X-rays. The calculated sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of pleural effusion were 86% (62/72), 93% (37/40), 95% (62/65) and 79% (37/47), respectively, in a per-hemithorax analysis. In the quantification of effusion size, there were high correlations between VRI images and chest X-ray area as assessed by ImageJ (r = 0.67) and pixel count (r = -0.77). The level of agreement between VRI readings and ultrasonography was 75% (41/55), and correlation with the volume of fluid drained in therapeutic thoracentesis was moderate (r = -0.49). No side effects from the VRI recordings were documented. CONCLUSIONS: VRI can be used to detect and quantify pleural effusions.

PMID: 18974633 [PubMed - indexed for MEDLINE]

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Lung sound analysis in the diagnosis of obstructive airway disease.

Respiration. 2009;77(2):134-8

Authors: Wang Z, Jean S, Bartter T

BACKGROUND: Dyspnea is prevalent and has a broad differential diagnosis. Difficulty in determining the correct etiology can delay proper treatment. Non-invasively obtained acoustic signals may offer benefit in identifying patients with dyspnea due to obstructive airway disease (OAD). OBJECTIVES: The aim of this pilot study was to determine whether patients with acute dyspnea due to OAD had distinguishing features when studied with a computerized acoustic-based imaging technique. METHODS: Respiratory sounds from patients with dyspnea due to OAD (n = 32) and those with dyspnea not due to OAD (n = 39) were studied and compared with normal controls (n = 16). RESULTS: In patients without OAD and in controls, the ratios of peak inspiratory to peak expiratory vibration energy values (peak I/E vibration ratio) were remarkably similar, 6.3 +/- 5.1 and 5.6 +/- 4, respectively. For the OAD patients, the peak I/E vibration ratio was significantly lower at 1.3 +/- 0.04 (p < 0.01). In the patients without OAD and the controls, the ratios of inspiratory time to expiratory time (I/E time ratio) were again similar, 1.0 +/- 0.1 and 0.99 +/- 0.11, respectively. For the OAD patients, the I/E time ratio was significantly lower at 0.72 +/- 0.19 (p < 0.01). CONCLUSIONS: This modality was useful in identifying patients whose dyspnea was due to OAD. The ability to objectively and non-invasively measure these differences may prove clinically useful in distinguishing the operant physiology in patients presenting with acute dyspnea.

PMID: 19033680 [PubMed - indexed for MEDLINE]

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Pleural effusions in critically ill patients.

Respiration. 2008;76(3):241-8

Authors: Pneumatikos I, Bouros D

Pleural effusions (PEs) are common in critically ill patients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients. Their impact on the pathophysiology of acute respiratory failure remains unknown. They are usually small and uncomplicated transudates that are easily overlooked on a supine portable chest X-ray and do not require drainage or infectious exudates that always require thoracocentesis. The diagnosis of PEs in critically ill patients has been revolutionized with the advent of chest ultrasound allowing easy bedside quantification of pleural fluid and making thoracocentesis a safe procedure especially in high-risk patients on mechanical ventilation. CT provides a much more accurate evaluation of the size and location of PEs and is extremely helpful in the guidance of catheters into loculated fluid collections. Hemothorax in critically ill patients is usually related to trauma or surgical interventions and requires early drainage and possibly surgical exploration.

PMID: 18824883 [PubMed - indexed for MEDLINE]

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Parapneumonic pleural effusion and empyema.

Respiration. 2008;75(3):241-50

Authors: Koegelenberg CF, Diaconi AH, Bolligeri CT

At least 40% of all patients with pneumonia will have an associated pleural effusion, although a minority will require an intervention for a complicated parapneumonic effusion or empyema. All patients require medical management with antibiotics. Empyema and large or loculated effusions need to be formally drained, as well as parapneumonic effusions with a pH <7.20, glucose <3.4 mmol/l (60 mg/dl) or positive microbial stain and/or culture. Drainage is most frequently achieved with tube thoracostomy. The use of fibrinolytics remains controversial, although evidence suggests a role for the early use in complicated, loculated parapneumonic effusions and empyema, particularly in poor surgical candidates and in centres with inadequate surgical facilities. Early thoracoscopy is an alternative to thrombolytics, although its role is even less well defined than fibrinolytics. Local expertise and availability are likely to dictate the initial choice between tube thoracostomy (with or without fibrinolytics) and thoracoscopy. Open surgical intervention is sometimes required to control pleural sepsis or to restore chest mechanics. This review gives an overview of parapneumonic effusion and empyema, focusing on recent developments and controversies.

PMID: 18367849 [PubMed - indexed for MEDLINE]

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Diagnostic work-up of pleural effusions.

Respiration. 2008;75(1):4-13

Authors: Froudarakis ME

A wide range of diseases may be the cause of an accumulation of fluid in the pleural space. Pleural effusion is a major diagnostic problem, since the pleura is an inner cavity with no direct access. The aim of this review is to provide a practical approach to the investigation of the patient presenting with pleural effusion. This should help to accurately diagnose pleural effusion and keep time-consuming, but necessary, invasive investigations to the minimum.

PMID: 18185024 [PubMed - indexed for MEDLINE]

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