Andrew G. Villanueva

Spontaneous hemothorax. Report of 6 cases and review of the literature.

We present 6 cases of spontaneous hemothorax and comprehensively review the medical literature on this subject. We categorize the reported causes and offer a rational diagnostic approach to patients with nontraumatic hemothorax. We recommend specific treatments for specific etiologies, and emphasize the importance of well-established surgical principles for the treatment of hemothorax. Our suggestions should enable physicians to accurately diagnose and expeditiously treat patients with spontaneous hemothorax.

Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.

BACKGROUND--A study was undertaken to compare the efficacy of short term tube thoracostomy drainage with standard tube thoracostomy drainage before instillation of tetracycline for sclerotherapy of malignant pleural effusions. METHODS--The study consisted of a randomised clinical trial in a sequential sample of 25 patients with malignant pleural effusions documented cytopathologically. Fifteen patients were randomly assigned to group 1 (standard protocol) and 10 to group 2 (short term protocol). Patients in group 1 had tube thoracostomy suction drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was < 150 ml/day, before tetracycline (1.5 g) was instilled. The chest tube was removed when the amount of fluid drained after instillation was < 150 ml/day. Patients in group 2 also had suction drainage, but the tetracycline (1.5 g) was instilled when the chest radiograph showed the lung to be re-expanded and the effusion drained, which was usually within 24 hours. The chest tube was removed the next day. RESULTS--The response to tetracycline sclerotherapy in the two groups was the same (80%) but the duration of chest tube drainage was significantly shorter for patients in group 2 (median two days) than for those in group 1 (median seven days). CONCLUSIONS--The duration of chest tube drainage before sclerotherapy for malignant pleural effusions need not be influenced by the amount of fluid drained daily but by radiographic evidence of fluid evacuation and lung re-expansion. Shorter duration of drainage will reduce the length of hospital stay without sacrificing the efficacy of pleurodesis.

Lung injury following thoracoscopic talc insufflation: experience of a single North American center.

BACKGROUND Thoracoscopic talc insufflation (TTI) has been used to obliterate the pleural space and prevent recurrent pleural effusions or pneumothorax. Reports of acute pneumonitis and ARDS after the use of talc raised concern about its safety. Differences in particle size of various talc preparations may explain the variable occurrence of pneumonitis. We sought to determine the incidence of lung injury after TTI over a 13-year period at our institution. METHODS Patients who underwent TTI between January 1994 and July 2007 were identified from a prospectively maintained logbook. The talc used was commercially available sterile talc (Sclerosol). The hospital course was reviewed in detail, and all cases of respiratory insufficiency were examined with regard to onset, suspected cause, and outcome. Talc-related lung injury was defined as the presence of new infiltrates on chest radiograph and increased oxygen requirements, with no other identifiable trigger than talc exposure. RESULTS A total of 138 patients underwent 142 TTIs for recurrent pleural effusions or spontaneous pneumothorax. TTI was performed most frequently for malignant pleural effusions (75.5% of effusions). The median dose of talc was 6 g (range, 2-8 g). Dyspnea with increased oxygen requirements developed within 72 h postprocedure for 12 patients. Four patients (2.8%) had talc-related lung injury, and talc exposure may have contributed to the respiratory deterioration in four additional patients. CONCLUSIONS We report the occurrence of lung injury after TTI using the only talc approved by the US Food and Drug Administration. These results reinforce previous concerns regarding the talc used for pleurodesis in North America.

Supplemental Oxygen Therapy

Intensivists caring for critically ill patients in a surgical intensive care unit continually face multiple diverse and challenging problems. While the specific disease processes in these patients are myriad, a fundamental goal is to provide adequate cellular respiration and thereby maintain sufficient tissue oxygenation and normal organ function. Successful cellular respiration depends on the maintenance of several factors, including adequate alveolar ventilation, a functioning gas-exchange surface, the capacity to transport oxygen to the tissue, and intact tissue respiration (the mitochondrial cytochrome oxidase system). Subsequent chapters in this textbook describe problems with each of these factors and how intensivists should approach and manage them. This chapter focuses on alveolar ventilation and how to use supplemental oxygen therapy to improve arterial oxygenation in patients who are hypoxemic but do not require mechanical ventilation.

The Long-term Prognosis of Patients With the Diagnosis of Nonmalignant Pleural Effusions After Pleuroscopy.

PurposeSeveral studies have demonstrated the diagnostic yield of medical thoracoscopy (pleuroscopy) in making the diagnosis of malignant pleural effusion (MPE). No previous studies, however, have reported long-term outcomes for patients undergoing diagnostic pleuroscopy in whom no malignancy was demonstrated either with cytologic examination of pleural fluid or pathologic examination of thoracoscope-guided pleural biopsies. We report the results of long-term follow-up (at least 3 y) of patients with the diagnosis of nonmalignant pleural effusions (NMPEs) after pleuroscopy. MethodsOne hundred and nineteen patients underwent the procedure between 1994 and 2003 at Lahey Clinic. We report a retrospective review of 25 of those patients diagnosed with NMPE after diagnostic pleuroscopy. All 25 patients underwent thoracoscopic pleural biopsy and cytologic examination of the effusion. Outcomes were assessed using review of the medical records, appointment scheduler, social security death index, and/or telephone conversation with primary care providers. ResultsMean age±SD was 68 years (range, 34 to 87 y). Median survival time was estimated at 114 months. Concomitant illness was also evaluated: 40% (n=10) diabetes, 64% (n=16) coronary artery disease, 40% (n=10) congestive heart failure, 20% (n=5) liver disease, 20% (n=5) renal disease, and 36% (n=9) pulmonary disease. Final diagnoses after pleuroscopy most commonly included chronic pleuritis (n=7) and pleural plaques (n=5). Survival was found at 1 year to be 88% (22/25), 3 years 80% (20/25), and 5 years 74.7% (19/25). None of the 25 patients developed subsequent MPE. ConclusionsPatients with NMPE after pleuroscopy have a favorable prognosis and are unlikely to be subsequently diagnosed with an MPE.

Management of Malignant Pleural Effusions

The development of pleural effusions is a common occurrence in patients with neoplastic disease. In one postmortem study, 15 % of patients who died with malignancies were found to have malignant pleural effusions, and the annual incidence of malignant pleural effusions (MPE) in the United States is estimated to be >150,000 cases. The presence of a MPE often portends a poor prognosis; the mean survival after the diagnosis of a MPE ranges from 3 to 12 months, depending on the underlying tumor (lung cancer is generally associated with the shortest average survival time). Patients with MPE often have symptoms that impair their quality of life, such as dyspnea, orthopnea, cough, and chest discomfort, some or all of which can be improved with palliative therapeutic measures.

Diffuse pulmonary infiltrates in an old man with chronic lymphocytic leukemia

An 82-year-old man known case of chronic lymphocytic leukemia (CLL) presented with fever and weakness. He had never received any treatment for his CLL in the past. On admission he was found to be in mild respiratory distress with bilateral crackles and had markedly elevated white blood count (WBC) (137 K/uL with 93% lymphocytes). His respiratory status deteriorated necessitating non-invasive ventilatory support. Chest computed tomography (CT) scan revealed bilateral diffuse ground glass opacities, so broad spectrum antibiotic therapy was initiated. Despite that, he remained febrile and cultures were all negative. Chest x-rays showed progressive worsening of diffuse alveolar opacities. Bronchoalveolar lavage (BAL) was negative for infectious etiologies, however flow cytometry of the fluid was consistent with CLL. Chemotherapy with chlorambucil was started. Although most of the pulmonary infiltrates in CLL patients are due to infectious causes, leukemic cells infiltration should be considered as well in CLL patients with respiratory symptoms who do not respond appropriately to standard antimicrobial regimen.