Jader Joel Machado Junqueira

Is Full Postpleurodesis Lung Expansion a Determinant of a Successful Outcome After Talc Pleurodesis

STUDY OBJECTIVES To analyze and compare radiologic lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary end points evaluated were as follows: clinical efficacy; quality of life; safety; and survival. METHODS Prospective randomized study that included 60 patients (45 women, 15 men; mean age, 55.2 years) with recurrent malignant pleural effusion between January 2005 and January 2008. They were randomized into the following two groups: video-assisted thoracic surgery (VATS) talc poudrage; and talc slurry (TS) administered through a chest tube. Lung expansion was evaluated through chest CT scans obtained 0, 1, 3 and 6 months after pleurodesis. Complications, drainage time, hospital stay, and quality of life (Medical Outcomes Study 36-item short form and World Health Organization quality-of-life questionnaires) were also analyzed. RESULTS There were no significant differences in preprocedure clinical and pathologic variables between groups. The immediate total (ie, > 90%) lung expansion was observed in 27 patients (45%) and was more frequent in the VATS group (60% vs 30%, respectively; p = 0.027). During follow-up, 71% of the patients showed unaltered or improved lung expansion and 9 patients (15%) needed new pleural procedures (VATS group, 5 recurrences; TS group, 4 recurrences; p = 0.999). No differences were found between groups regarding quality of life, complications, drainage time, hospital stay, and survival. Immediate lung expansion did not correlate with radiologic recurrence, clinical recurrence, or complications (p = 0.60, 0.15, and 0.20, respectively). CONCLUSION Immediate partial lung expansion was a frequent finding and was more frequent after TS. Nonetheless, no correlation between immediate lung expansion and clinical outcome was found in this study. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NTC00789087.

Perfil do doador de pulmão disponibilizado no estado de São Paulo, Brasil, em 2006

OBJECTIVE: To analyze the rate at which lungs available for transplantation in the state of Sao Paulo in 2006 were utilized and to determine the lung donor profile in the same period. METHODS: A retrospective study of 497 clinical charts of lung tissue donors from January to December of 2006. RESULTS: According to the clinical charts, lungs were not offered for transplant in 149 cases (30%), which were therefore excluded from the study. Among the 348 lung donors eligible for inclusion in the study, the mean age was 37.4 ± 16.1 years, and 56.9% were males. The main causes of brain death among the donors were stroke (in 40.5%), skull-brain trauma (in 34.2%) and subarachnoid hemorrhage (in 10.9%). The great majority of these lung donors (90.5%) received vasoactive agents, and 13.5% presented cardiopulmonary arrest. The mean donor leukocyte count was 15,008 ± 6,467 cells/mm³, 67.8% of the donors received anti-bacterial agents, and 26.1% presented lung infection. Nearly 40% of the lung donors presented chest X-ray abnormalities. Only 4.9% of the lung donors were accepted, representing 28 lungs (allograft utilization rate of 4%). The causes for donor exclusion were gas exchange alterations (in 30.1%), infection (in 23.7%) and distance (in 10.9%). CONCLUSIONS: The lung utilization rate in the state of Sao Paulo is low when compared to mean rates worldwide. In addition, more than half of the donor pool was excluded due to altered gas exchange or pulmonary infection. The combination of better care of the potential donor and more flexible selection criteria could increase allograft utilization.

Bronchial complications following lung transplantation.

INTRODUCTION Bronchial complications owing to the airway anastomosis in lung transplantation are important causes of morbidity and mortality. They occur in up to 27% of cases as defined by stenosis, necrosis, and dehiscence. Treatment depends on the type of complication. OBJECTIVE To report our experience to treat this complication. METHODS Between 2000 and 2007, we performed 71 lung transplants of which 36 were bilateral. The total number of anastomoses was 107:52 to the right and 55 to the left. The telescoping technique was initially used (14 initial unilateral transplants), and after October, 2003 it was changed to an end-to-end anastomosis (57 transplants and 93 anastomoses). RESULTS Eight patients developed bronchial complications including two that were bilateral. There were 4 stenosis, 3 dehiscences, and 3 necrosis complications (9.4%). The complication rate for telescoping anastomosis was 21.4%, and for the end-to-end technique, 7.5%. The treatment of the stenosis used metallic or plastic self-expandable stents. Two bronchial dehiscences resulted in case of bronchopleural fistulae, empyema, and death; the other patient experienced spontaneous resolution. Concerning bronchial necrosis, 1 patient developed fistulization to the pulmonary artery and massive hemoptysis, and the other with bilateral necrosis, a spontaneous resolution. CONCLUSION Our bronchial anastomosis complication rate was comparable with that in other reports. The rate for the telescoping technique was greater compared with the end-to-end technique. The treatment of bronchial stenosis with a self-expandable prosthesis showed good results.

Pulmonary Artery Sarcoma Mimicking a Pulmonary Artery Aneurysm

Pulmonary artery sarcoma is an uncommon neoplasm, and its clinical and radiological presentation usually simulates chronic thromboembolic disease. We present the case of a 77-year-old woman admitted with dyspnea, chest pain, and hemoptysis. A chest computed tomographic scan showed moderate right-sided pleural effusion and a saccular dilatation of the interlobar portion of the right pulmonary artery, which was filled with contrast and surrounded by an irregular soft-tissue attenuation mass, suggesting a ruptured pulmonary artery aneurysm. The patient was operated on. Intraoperatively, a pseudoaneurysm and a solid mass were identified within the oblique fissure around the interlobar artery. Therefore, a right pneumonectomy was performed. Definitive pathologic examination was consistent with pulmonary artery sarcoma. The patient had a good outcome and is free of disease 2 years after surgery.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation

BACKGROUND Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS The study group comprised 552 patients with a mean age of 69.6 +/- 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34% (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.

Derrame pleural secundário à hiperestimulação ovariana

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Hiperinsuflação pulmonar após transplante unilateral por enfisema

Despite preventive measures, lung hyperinflation is a relatively common complication following single lung transplantation to treat pulmonary emphysema. The progressive compression of the graft can cause mediastinal shift and respiratory failure. In addition to therapeutic strategies such as independent ventilation, the treatment consists of the reduction of native lung volume by means of lobectomy or lung volume reduction surgery. We report two cases of native lung hyperinflation after single lung transplantation. Both cases were treated by means of lobectomy or lung volume reduction surgery.

Tracheal Malignant Melanoma: Successful Outcome With Tracheal Resection

Primary tracheal malignant melanomas are uncommon neoplasms: only five cases have been reported. Different therapeutic approaches are described, with a short life expectancy observed. We report a case of a young woman with a primary tracheal malignant melanoma who underwent complete tracheal resection and is free of disease 4 years after surgical treatment.

Desordem linfoproliferativa pós-transplante em paciente pediátrico

Immunosuppressive therapy for transplanted patients exposes them to a high risk of developing posttransplantation lymphoproliferative disorders (PTLD). We report the case of a child undergoing heart transplantation at seven months of age who developed PTLD at nine years of age, diagnosed by resection of a pulmonary nodule.

Pneumothorax after acupuncture: clinical presentation and management

INTRODUCTION Pneumothorax is a rare but dangerous complication of acupuncture. Because of its rarity, there are few reports in literature and, therefore little information regarding clinical and therapeutic aspects. This article aims to analyze the clinical presentation, management and follow-up of patients with pneumothorax after acupuncture. METHODS Retrospective study of patients with post-acupuncture pneumothorax evaluated in a tertiary hospital during a five-year period (2001-2006). RESULTS Five patients (3 male and 2 female), mean age 46 years (30-73) were included. All patients but one (who had a bilateral pneumothorax) had left-sided pneumothorax . Chest pain, which was the initial symptom in all patients was severe in three cases and mild in two. Four patients underwent tube thoracostomy (pig-tail catheter), three of them immediately after admission and the other after a failed 12-hour conservative treatment period. One patient had a successful conservative management. All had an excellent outcome and were asymptomatic and exhibited a normal chest X-ray at 6-month follow-up CONCLUSION In all patients, the initial symptom was chest pain, of varying intensity. Tube thoracostomy was the therapeutic modality most frequently employed. All patients had a successful outcome with no further complications.