Juan Ossés

Open lung biopsy for diffuse disease in patients with and without previously transplanted solid organs.

BACKGROUND Studies on whether surgical lung biopsy (SLB) modifies the treatment of patients with diffuse lung disease are conflicting, and information is limited on whether it alters treatment in solid-organ transplant recipients. Our objective was to determine and compare the rate of treatment change after SLB for diffuse lung disease in patients with and without a history of solid-organ transplantation. METHODS Patients undergoing SLB for diffuse lung disease between March 2004 and March 2009 were identified. A retrospective review was performed. RESULTS Sixty patients had SLB. Thirty-four patients (57%) had solid-organ transplantation. Twenty of 60 patients (33%) had a change in treatment as a result of the findings of the SLB. No significant differences in the treatment change rate were found between the transplant and nontransplant groups (10 of 34 versus 10 of 26; p = 0.46). Transplant patients were more likely to be on mechanical ventilation at the time of SLB (12 of 34 versus 3 of 26; p = 0.03). Mechanical ventilatory support at the time of SLB was associated with increased postoperative complications (odds ratio, 6.20; 95% confidence interval [CI], 1.70 to 22.66; p = 0.006) and in-hospital mortality (odds ratio, 9.75; 95% CI, 2.54 to 37.38; p = 0.001). Being on mechanical ventilation (hazard ratio, 3.91; 95% CI, 1.40 to 10.93; p = 0.009), a diagnosis of cancer (hazard ratio, 13.20; 95% CI, 2.87 to 60.78; p = 0.001), and a history of solid-organ transplantation (hazard ratio, 5.52; 95% CI, 1.08 to 28.14; p = 0.04) were independent predictors of survival. CONCLUSIONS Surgical lung biopsy changes treatment in one third of patients, with no significant difference between patients without transplantation and solid-organ transplant recipients. Patients who undergo SLB while on mechanical ventilation have a significantly increased risk of postoperative complications and death.

The use of non-invasive ventilation during fiberoptic bronchoscopy in patients with high risk of orotracheal intubation

Introduction: The realization of fiberoptic Bronchoscopy (FBC) in patients with Severe Respiratory Failure (SRF), non-intubated and with high oxygen requirements, is contraindicated due to risk of serious arrhythmias or abrupt deterioration of ventilatory mechanics. Studies have shown that ventilation using non invasive (NIV) as support of breathing during the FBC in patients with SRF, is a safe and effective alternative to intubation, allowing an adequate gas exchange. Methods: We prospectively assessed patients hospitalized in ICU, with SRF, not intubated requiring FBC and bronchoalveolar lavage on suspicion of nosocomial pneumonia. The procedure was performed through facial mask, connected to a double level of pressure generator, Bilevel, with an O2 port. During the study, tolerance, oxygen saturation and ventilatory parameters were monitorized. Results: 22 patients (10 women) were included, the mean age was 55 years (range 13-82), 7 patients with lung transplant, heart transplant 2, 7 in postoperative cardiac surgery, 1 post-op Bariatric Surgery, 5 hospitalized for clinical reasons. Inspiratory Positive Airway Pressure levels used between 8 and 22 cmH2o and Expiratory Positive Airway Pressure levels between 4 and 10 cmh2o. The FiO2 was between 35% and 40%. The exhaled tidal volume average was 492 ml. The initial respiratory rate average was 25 and 26 at the end of the procedure. The media Sao2, at the beginning and at the end of the study was 96% and 95%, respectively.No patient presented arrhythmias or required intubation. Conclusion: The use of NIV for the FBC represents a safe and effective alternative, avoiding intubation in patients with SRF.