Robert H. Poe

Can Postoperative Pulmonary Complications After Elective Cholecystectomy be Predicted

To determine predictors of postoperative morbidity in elective cholecystectomy patients, the authors examined prospectively the consequences of age, sex, active and past smoking, respiratory history, obesity, type of surgical incision, and preoperative pulmonary function, upon the incidence of postoperative pulmonary complications and length of hospi-talization. They identified 31 (14.8%) complications in 209 patients; 21 had atelectasis, 8 purulent bronchitis, and 2 pneumonia. These patients averaged 1.5 days longer in the hospital (p <0.001 by analysis of variance) than control patients. Abnormal spirometry (MEFV) and the single-breath nitrogen test (SBN2) were significant predictors of postoperative pulmonary complications (p<0.001 by discriminant analysis method). Active smoking and history of respiratory disease were associated with abnormal small airway function (p<0.001 by chi-square test), but did not predict postoperative morbidity. By analysis of variance, only a reduction in preoperative FVC emerged as predictive of prolonged hospitalization (p<0.001). These results were used to determine if the selection of patients by preoperative pulmonary function testing permits more cost-effective administration of respiratory therapy (RT) services. Neither the MEFV nor SBN2 had sufficient specificity to enhance the cost effectiveness of postoperative RT.

Case Report The rapid development of an aspergilloma secondary to allergic bronchopulmonary aspergillosis

Abstract A patient with allergic bronchopulmonary aspergillosis who developed a cavitary lung lesion suggestive of neoplasm is presented. At thoracotomy an aspergilloma was found. Although coexistence of these two forms of aspergillosis has been reported, the brief history of preceding asthma and the rapid developement of the aspergilloma in the absence of typical roentgenographic features are unusual. Aspergilloma should be considered when a patient with allergic bronchopulmonary aspergillosis develops a cavitary pulmonary lesion.

Tropical Pulmonary Eosinophilia Masquerading as Acute Bronchial Asthma

With the influx of immigrants from developing countries, deployment of American troops on foreign soil, and wide-ranging travel patterns of some United States citizens, one should expect an increase in the frequency of parasitic pulmonary diseases. We report a case of tropical pulmonary eosinophilia in a recent immigrant to Upstate New York from India. Tropical pulmonary eosinophilia is unfamiliar to most physicians practicing in North America, but should be included in the differential diagnosis of asthmatic bronchitis with hypereosinophilia when there is a history of recent travel to or residence in endemic areas. Furthermore, knowledge of this entity should also help in the differential diagnosis of other hypereosinophilic syndromes.

Pleural effusion in yellow nail syndrome : chemical pleurodesis and its outcome

Two cases of yellow nail syndrome (a triad of yellow dystrophic nails, chronic lymphedema and pleural effusion) are described which demonstrate long-term control of recurrent pleural effusions by tetracycline pleurodesis. Neither patient developed problems as a result of the procedure enabling us to conclude that tetracycline pleurodesis is effective in managing reaccumulating pleural fluid in yellow nail syndrome and may avoid loss of lung function due to pleural peel.

Massive Pericardial Effusion in Sarcoidosis

Massive pericardial effusion in sarcoidosis is rare. We summarize the features of a recent patient along with a review of 9 previously reported cases. All but 1 patient with massive pericardial effusion were female and all had massive cardiomegaly on their chest roentgenogram with 7 of the 10 also showing features suggestive of sarcoidosis (bilateral hilar adenopathy with or without interstitial infiltrates). Nine of the 10 patients required a drainage procedure (pericardiectomy or pericardiocentesis). Pericardial histology revealed noncaseating granulomas in 6 of 7 patients. Two of the patients expired within the first week of hospitalization with evidence of myocardial involvement. The remainder of the patients have had clinical stability most responding to steroids, yet recurrences were seen in 3 patients and 1 patient required cyclophosphamide for control.

Pulmonary blastomycosis versus carcinoma ??? a challenging differential

A review of clinical records of the past 10 years at the Cincinnati General, Cincinnati Veterans Administration, Christ, Good Samaritan, Jewish, and Holmes Hospitals, Cincinnati, yielded 25 patients with proven pulmonary blastomycosis. Eleven presented with findings suggestive of a diagnosis of primary carcinoma of the lung and one with carcinoma of the larynx and pulmonary metastases. The clinical presentation was varied; three were asymptomatic. Seven of the 12 underwent major surgical procedures before the diagnosis was apparent. An eighth was diagnosed by laryngeal biopsy. Three of the remaining four were bronchoscoped but were actually diagnosed when previously collected sputums grew Blastomyces dermatitidis. The remaining patient had pulmonary infiltrates, a bone lesion, and a positive skin biopsy for blastomycosis. An expeditious diagnostic approach is warranted when carcinoma is suspected, but prudent attention to the possibility of blastomycosis might save an occasional patient an otherwise unnecessary surgical procedure.

Survival of patients with pleural involvement by breast carcinoma

To determine factors which affect survival in patients with pleural involvement by breast carcinoma, we reviewed records of all patients at two community teaching hospitals presenting with malignant pleural effusion over a 6-year period. Forty-five patients had had mastectomy for breast cancer, no history of other malignancy, and cytologic confirmation of subsequent pleural metastases. All had received conventional combination systemic chemo- or hormonal therapy. Ten patients (group 1) in whom effusion was the initial and only site of recurrent disease had a median survival of 48 months. The median survival was 12 months in 35 patients (group 2) who developed effusion in association with other metastatic disease. Half of the patients in group 1 had no axillary node involvement at mastectomy. Twenty-eight patients (80%) in group 2 had had more advanced disease at initial diagnosis. This, and behavior of the effusion as regional rather than systemic disease, suggested by the high incidence of effusion on the ipsilateral side of the mastectomy, probably accounts for the better outlook in patients with effusion alone.

Acute respiratory distress syndrome with pulmonary calcification in two patients with B cell malignancies.

Two patients, one with B cell lymphoma and hypercalcemia and the other with multiple myeloma and hypercalcemia developed acute progressive respiratory insufficiency characteristic of the adult respiratory distress syndrome (ARDS). Both were intubated and placed on mechanical ventilation. Lung compliance deteriorated and became refractory to mechanical inflation. Examination of the lungs at post mortem examination disclosed widespread calcification within alveolar septa and diffuse alveolar damage with hyaline membrane formation consistent with ARDS. Although ARDS has been described with lymphomatous involvement of the lungs, its development in association with metastatic calcification in B cell malignancy has not been previously reported.

Bronchial Provocation Tests before and after Cessation of Smoking

We studied the effect of smoking cessation on airway reactivity. We recruited cigarette smokers who were attempting to stop smoking. Entry criteria required each subject to be smoking at least 10 cigarettes each day and report a chronic cough. Exclusion criteria included significant airflow obstruction or the presence of any medical condition contraindicating challenge testing. Carbachol challenge was performed to assess airway reactivity according to a standardized method. Baseline measurements of forced expiratory volume in 1 s (FEV1), specific airway conductance (SGaw) and the provocative dose of carbachol causing a 35% reduction in SGaw (PD35), and a 20% reduction in FEV1 (PD20) were established on entry while each subject was still smoking. Thereafter, repeat measurements were performed after 2 and 6 months of smoking cessation. Adherence to smoking cessation was checked by self-report and verified by measurement of alveolar carbon monoxide levels at each session. Of the 34 subjects who gave consent, 13 relapsed prior to the 2nd month and an additional 8 relapsed before the 6th month. Thirteen of the 34 remained abstinent throughout the 6-month study. All 13 subjects had complete resolution of their cough. The difference in reactivity on entry to that at the 2nd and 6th month was not significant. We conclude that (1) the symptom of chronic cough resolved completely after 2 months of smoking cessation, and (2) airway reactivity remained unchanged at 2 and 6 months of smoking cessation.

Small Airway Testing and Smoking in Predicting Risk in Surgical Patients

A prospective study was performed on 185 surgical patients without overt respiratory disease to determine whether three sensitive tests for early airway obstruction or cigarette smoking at the time of hospitalization were useful in identifying the patient at risk for a postoperative pulmonary complication. Subjects were evaluated by questionnaire. Pulmonary function testing consisted of the single breath nitrogen test (SBN2) to determine the closing volume (CV) and slope of the alveolar plateau, and a maximum expiratory flow volume curve (MEFV) to determine expiratory flow at low lung volumes. Fifty-five patients had upper abdominal surgery and 130 a major surgical procedure under general or spinal anesthesia upon another part of the body. Ninety-six (52%) of the 185 patients were smokers. Seventy-nine patients (43%) had one or more abnormal function parameters. The CV was abnormal in 59, alveolar plateau in 18, and MEFV in 12. Fifty-four percent of smokers and 30 percent of nonsmokers had abnormal small airway tests. Sixteen of 185 patients (8.6%) developed a postoperative respiratory complication determined by review of the hospital record. Eleven were in the 96 smokers, but 13 were in the 79 patients with abnormal small airway tests. The incidence was highest (38%) in smokers with an abnormal alveolar plateau who underwent upper abdominal surgery. Identification of the patient at risk was better served by tests of small airway abnormality than by smoking history alone.