Nancy Munn

Effectiveness of short-course therapy (5 days) with grepafloxacin in the treatment of acute bacterial exacerbations of chronic bronchitis

Three hundred eighty-nine patients were enrolled in a double-masked, multicenter, randomized clinical trial comparing the clinical and bacteriologic efficacies and safety of a 5-day course (n = 195) versus a 10-day course (n = 194) of grepafloxacin 400 mg once daily in the treatment of acute bacterial exacerbations of chronic bronchitis (ABECB). Patients in the 5-day treatment group received placebo on days 6 through 10. Bacteriologic assessments were based on cultures of sputum specimens obtained before and, when possible, during and after treatment. Organisms were isolated from the pretreatment sputum specimens of 332 of 388 (86%) patients, the primary pathogens being Haemophilus parainfluenzae, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus (29%, 19%, 4%, 5%, and 5% of isolates, respectively). Among isolates tested for beta-lactamase production, results were positive in 25% of H influenzae isolates and 90% of M catarrhalis isolates. Forty-two percent of S pneumoniae isolates demonstrated reduced susceptibility (intermediate or high-level resistance) to penicillin. A satisfactory clinical outcome (cure or improvement) was achieved in 83% (128 of 155) and 81% (122 of 150) of clinically evaluable patients treated with grepafloxacin for 5 or 10 days, respectively. Pathogens were eradicated or presumed eradicated in 77% (106 of 138) and 80% (98 of 123) of bacteriologically evaluable patients treated with grepafloxacin for 5 or 10 days, respectively. The 2 treatment groups were equivalent with respect to both clinical and bacteriologic efficacy, and no statistically significant differences in the incidence of drug-related adverse events were seen between the 2 groups. Substantial symptom relief was evident with both treatment regimens by the first during-treatment measurement, which occurred between days 3 through 5. These results indicate that treatment with 400 mg grepafloxacin once daily for 5 days is as well tolerated and effective as treatment for 10 days in patients with ABECB. The lower cost compared with a 10-day regimen and the increased likelihood that patients will complete the entire shorter, once-daily regimen make the 5-day grepafloxacin regimen a useful therapeutic option in the treatment of ABECB.

Severe Pneumomediastinum Complicating EBUS-TBNA.

To the Editor: Pneumomediastinum infrequently complicates diagnostic bronchoscopy. Increased airway or alveolar pressure results in air leaks to the mediastinum through existing or induced defects. Excessive cough, recurrent episodes of increased abdominal pressure, vomiting, or sneezing can all induce spontaneous pneumomediastinum. Less commonly it has been documented with lung or neck infections, esophageal or tracheal tears, and rapid increases in altitude such as during plane flights or scuba diving, with mechanical ventilation, substance abuse, and after bronchoscopy. Pneumomediastinum may be, but is not always, associated with pneumothorax. We recently evaluated a 63-year-old male patient with a 2-day history of hemoptysis and a left upper-lobe lung mass with hilar adenopathy and a postobstructive process. Flexible white light bronchoscopy showed a normal airway except for an occluded left upper-lobe bronchus with sparing of the lingula. Multiple forceps biopsies were obtained from the apparent endobronchial lesion. Endobronchial ultrasound (EBUS)-guided lymph node biopsies were obtained from stations 4R, 4L, 7, and 11L. During the procedure there were no complications and no bleeding. The pathology report revealed moderately differentiated squamous cell cancer from only the left upper-lobe endobronchial biopsies. One day after discharge the patient returned to the emergency room with recurrent severe cough and chest and neck pain associated with increasing swelling of the neck. There was no hemodynamic or respiratory compromise. CT scan of the chest and neck (Fig. ​(Fig.1)1) to investigate the neck and chest “swelling” showed pneumomediastinum with extensive subcutaneous emphysema with no apparent pneumothorax. The patient was treated with cough suppressants, analgesics, and stool softeners, along with oxygen supplementation through a nasal cannula. The pneumomediastinum and subcutaneous emphysema resolved without any other intervention. The pneumomediastinum was felt to be iatrogenic and was most likely related to the bronchoscopic procedure. FIGURE 1 CT scan of the chest and neck showing pneumomediastinum and subcutaneous air (arrows). Lung mass in the left upper lobe (asterisk). Bronchoscopy with endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) is considered to be a very safe procedure and is certainly less invasive than mediastinoscopy or percutaneous needle biopsy. It has been increasingly utilized for the diagnosis of sarcoidosis, for unexplained mediastinal adenopathy, and for lung cancer staging. Complications from EBUS-TBNA are rare. Focal tracheal stenosis secondary to intramural hematoma following EBUS-TBNA has been reported.1 Barotrauma after ablation techniques has previously been seen.2 Pneumothorax was reported in 0.03% (2/7345) of procedures in a survey of 455 facilities in Japan.3 There was no pneumomediastinum reported. Hemorrhagic and infectious complications were the most common. A review of the AQuIRE registry for complications revealed no reported cases of pneumomediastinum, with a rate of pneumothorax of 0.2% reported among patients who did not undergo transbronchial biopsies.4 In a comprehensive review of all published articles on endosonography of the mediastinum (EBUS or EUS or their combination) from 1995 to 2012, von Bartheld et al5 did not report any case of pneumomediastinum. Most complications from this procedure were infectious. EUS was the main risk factor for complications, with 18 of 23 serious complications being observed in this group, compared with EBUS. To our knowledge, this is the first case of pneumomediastinum that is associated with EBUS-TBNA. It is unlikely that the positive pressure ventilation used during the procedure caused the pneumomediastinum. The procedure was performed through the LMA utilizing general anesthesia but with spontaneous ventilation and 5 cm water pressure support. In addition, the patient presented with pneumomediastinum >24 hours after the procedure, which makes it less likely to be related to the positive pressure and more likely related to a defect created by the procedure in the bronchial wall and exacerbated by cough. Although the direct cause of the pneumomediastinum cannot be certainly established, whether related to the TBNA or to the endobronchial biopsy, we would like to alert other bronchoscopists of the potential rare complication and stress upon the fact that conservative therapy should be the first line of treatment. Treatment should be aimed at decreasing intrathoracic pressure spikes by reducing coughing and straining. Oxygen therapy might hasten reabsorption of the subcutaneous nitrogen bubble as it does to a pneumothorax.

Mechanical Ventilation Management by Pulmonologists and Surgeons in Patients With Adult Respiratory Distress Syndrome

Background:Treatment of patients with acute respiratory distress syndrome (ARDS) is complex, and management by a specialist with expertise in pulmonary mechanics may improve outcomes. We compared mechanical ventilation management of patients with ARDS by pulmonologists and surgeons. Methods:We retrospectively reviewed 97 patients with an ICD-9 diagnosis of ARDS at 2 community hospitals. We collected information on demographics and all necessary parameters to calculate the acute physiology, age, and chronic health evaluation (APACHE II) score. Main outcomes included mortality and total days spent in the intensive care unit (ICU) and on mechanical ventilation. All outcomes were adjusted for APACHE II score using multiple logistic regression. Results:Mechanical ventilation was managed by a pulmonologist in 62 patients and by a surgeon in 35 patients. Mortality rate was 35.5% (n = 22) in the patients treated by pulmonologists and 45.7% (n = 16) in patients treated by surgeons (P = 0.32). This result was unaffected by adjustment for APACHE II score. However, those surviving spent fewer days in the ICU (median of 10 vs 16 days; P = 0.07) and fewer days on mechanical ventilation (median of 7 vs 15 days; P = 0.003) when treated by pulmonologists. These results were unaffected by adjustment for APACHE II score. Conclusions:We found that patients who survived with ARDS spent fewer days on mechanical ventilation, and there was a trend for spending fewer days in the ICU when mechanical ventilation is managed by a pulmonologist compared with a surgeon. There was a lower mortality rate in the pulmonologist group, although this did not reach statistical significance. A small sample size and the retrospective design limit our findings. Further study using a multicenter design to determine if a disease specific specialist improves efficiency of care is needed because if our findings are confirmed, it would translate into significant cost savings.

The role and safety of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and management of infected bronchogenic mediastinal cysts in adults

Bronchogenic and other duplication cysts are congenital abnormalities that can present at any age including adulthood years. They are usually asymptomatic and discovered incidentally on radiological imaging of the chest. They are commonly treated by surgical resection. Recently, endobronchial ultrasound has been used to assist in diagnosis when radiologic imaging is not definitive. Endobronchial ultrasound has been used rarely to drain infected cysts, a rare complication of the bronchogenic cyst. We present a unique case of an infected large bronchogenic cyst treated with endobronchial ultrasound drainage combined with conservative medical therapy. We also review the scarce available literature describing such an approach and its potential complications and add recommendations based on our experience in managing these anomalies.

Urinothorax Caused by Xanthogranulomatous Pyelonephritis

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis that generally afflicts middle-aged women with a history of recurrent urinary tract infections. Its pathogenesis generally involves calculus obstructive uropathy and its histopathology is characterized by replacement of the renal parenchyma with lipid filled macrophages. This often manifests as an enlarged, nonfunctioning kidney that may be complicated by abscess or fistula. This case details the first reported case of xanthogranulomatous pyelonephritis complicated by urinothorax, which resolved on follow-up chest X-ray after robot-assisted nephrectomy.