Enrique Cases Viedma

Normativa sobre el diagnóstico y tratamiento del derrame pleural. Actualización

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques.

Eficacia del midazolam para la sedación en la broncoscopia flexible. Un estudio aleatorizado

INTRODUCTION Flexible bronchoscopy (FB) is a procedure which is not usually tolerated well by the patient. This makes the examination more difficult, often needing repetition with the subsequent lowering of diagnostic performance. OBJECTIVE The principal aim of our study is to analyse whether the use of a local anaesthetic with midazolam whilst performing an FB improves the quality of examination in terms of patient tolerance. Also of interest was to find out if this would improve the acceptance of a second or further FB, and the satisfaction of the bronchoscopist in performing these examinations. PATIENTS AND METHODS A randomised, double blind and controlled with placebo, prospective study has been carried out to assess the use of midazolam. This included 152 patients, randomised into two groups: Group A-79 (51.9%) patients who received midazolam before the FB, and Group B-73 (49.1%) patients who received placebo. The patients were given a questionnaire about different aspects of perception of the procedure after the respiratory endoscopy and another was given to the bronchoscopist. RESULTS Both groups started off with a similar assessment of fear and nervousness. Group A gave a much higher score than Group B referring to variables related to symptoms and feeling. Patient cooperation assessed by the bronchoscopist was similar in both groups, although the length of the procedure and difficulty was higher in group B. CONCLUSION Our results show that patients sedated with midazolam tolerate FB better, remember less of the procedure itself and have a better predisposition to repeat the procedure. The bronchoscopist has less difficulties during the procedure and shortens the time using the same techniques during the bronchoscopy. The lack of severe complications and these results suggest the use of sedation with midazolam as routine during FB.

A Randomised Study of Midazolam for Sedation in Flexible Bronchoscopy

Abstract Introduction Flexible bronchoscopy (FB) is a procedure which is not usually tolerated well by the patient. This makes the examination more difficult, often needing repetition with the subsequent lowering of diagnostic performance. Objective The principal aim of our study is to analyse whether the use of a local anaesthetic with midazolam whilst performing an FB improves the quality of examination in terms of patient tolerance. Also of interest was to find out if this would improve the acceptance of a second or further FB, and the satisfaction of the bronchoscopist in performing these examinations. Patients and methods A randomised, double blind and controlled with placebo, prospective study has been carried out to assess the use of midazolam. This included 152 patients, randomised into two groups: Group A—79 (51.9%) patients who received midazolam before the FB, and Group B—73 (49.1%) patients who received placebo. The patients were given a questionnaire about different aspects of perception of the procedure after the respiratory endoscopy and another was given to the bronchoscopist. Results Both groups started off with a similar assessment of fear and nervousness. Group A gave a much higher score than Group B referring to variables related to symptoms and feeling. Patient cooperation assessed by the bronchoscopist was similar in both groups, although the length of the procedure and difficulty was higher in group B. Conclusion Our results show that patients sedated with midazolam tolerate FB better, remember less of the procedure itself and have a better predisposition to repeat the procedure. The bronchoscopist has less difficulties during the procedure and shortens the time using the same techniques during the bronchoscopy. The lack of severe complications and these results suggest the use of sedation with midazolam as routine during FB.

Embolia pulmonar por mercurio elemental

La administracion intravenosa de mercurio es un hecho infrecuente que suele asociarse a inyecciones accidentales o a intentos de suicidio. A continuacion presentamos el caso de un varon de 42 anos que se administro mercurio intravenoso en la vena cubital izquierda con fines autoliticos. Acudio al servicio de urgencias por intoxicacion etilica. Presentaba signos de venopuncion con celulitis en el brazo izquierdo y se encontraba asintomatico desde el punto de vista respiratorio. La radiografia de torax mostraba multiples opacidades metalicas dispersas en ambos pulmones. El paciente fue ingresado y tratado con quelantes (dimercaprol) y hemodialisis. Al mes acudio de nuevo a urgencias con clinica respiratoria y presencia de derrame pleural derecho en la radiografia de torax.

Pulmonary Embolism Caused by Elemental Mercury

Intravenous mercury administration is a rare occurrence that is typically associated with accidental injections or suicide attempts. We report the case of a 42-year-old man who attempted suicide by injecting mercury into the left cubital vein. Upon arrival at the emergency department, he was in a state of alcohol intoxication and there were signs of vein puncture and cellulitis in his left arm. He had no respiratory symptoms. A chest x-ray revealed numerous metallic opacities dispersed throughout both lungs. He was admitted to hospital and treated with chelating agents (dimercaprol) and hemodialysis. A month later, the patient returned to the emergency department with respiratory symptoms, and a chest x-ray revealed right pleural effusion.

Biopsia pleural con aguja Tru-cut y citología como primer procedimiento en el estudio del derrame pleural

INTRODUCTION AND OBJECTIVES The evaluation of pleural effusion (PE) includes various techniques, including pleural biopsy (PB). Our aim was to study the diagnostic yield of Tru-Cut needle PB (TCPB) and to define clinical/radiological situations in which TCPB might be indicated as an initial procedure. METHODOLOGY Retrospective study of TCPB in a hospital centre (2010-2012). Cases of pleural lesions without effusion were excluded. Clinical and radiological variables, diagnostic yield, TCPB complications and factors associated with the diagnostic yield of the combination of TCPB and thoracocentesis as initial procedure were analysed. RESULTS One hundred and twenty-seven (127) TCPB were reviewed: 29.1% were cases of malignant PE and in 18.9% the cause of the PE could not be determined. The diagnostic yield of TCPB for tuberculosis was 76.5% (13/17) and 54% (20/37) for malignant PE. Complications occurred in 4.7% of the cases. In 72 patients with a final definitive diagnosis, TCPB was performed at the same time as the initial thoracocentesis. Diagnostic yield for the combination of TCPB/cytology as an initial technique was 43% (31/72) compared to 12.5% (9/72) for cytology only (p=0.01). The only predictive variable for the indication of TCBP as an initial technique was a PE volume>2/3 (P=.04). CONCLUSIONS TCPB is safe and provides an acceptable diagnostic yield, particularly when combined with simultaneous cytology in the evaluation of PE of various aetiologies. Radiological criteria may help guide the selection of patients who could benefit from this technique as an initial procedure combined with thoracocentesis.

Salvage therapy with topical posaconazole in lung transplant recipients with invasive Scedosporium infection

Scedosporium is an important pathogen in cystic fibrosis (CF) and post‐transplantation, but it rarely causes invasive infection. Treatment remains challenging, particularly due to the inherent resistance to multiple antifungal agents. We present 3 complicated invasive tracheobronchial and lung Scedosporium apiospermum infections following lung transplantation. In 2 of 3 cases, the infection was clinically and radiologically cured with frequent cleansing bronchoscopies, combining triazole with terbinafine therapy and nebulized posaconazole. These cases highlight the importance of adjunctive nebulized therapy in addition to prolonged triazole treatment to manage complex invasive Scedosporium infections in immunosuppressed patients. Posaconazole (PSZ) was delivered during the bronchoscopy procedure through intrabronchial administration, whereas an eFlow rapid® device was used for nebulized therapy. Topical posaconazole was well tolerated in 2 patients, with only a slight cough during administrations; the third patient had local irritation with poor tolerance, which led to its withdrawal. This is the first report on compassionate use of topical PSZ as salvage therapy for resistant mold infections in lung transplant recipients. These 3 cases represent the entire experience using this approach; no additional patients have received this therapy due to there not having been any additional cases of Scedosporium tracheobronchitis presented.