Salvador Díaz-Lobato

Use of spirometry to predict risk of pneumothorax in CT-guided needle biopsy of the lung.

OBJECTIVE Our goal was to assess the usefulness of spirometry to estimate the risk of pneumothorax in patients undergoing percutaneous needle biopsy with CT guidance for solitary pulmonary nodule (SPN). MATERIALS AND METHODS We studied the results of 51 consecutive percutaneous needle biopsies with CT guidance for SPN obtained between 1988 and 1990. Forty-five men and six women, aged 65 +/- 11 (36-86) years, were included in the study. All biopsies were performed under CT guidance, with 90 mm 25G needles (0.5 mm thickness) fitted into luer-type syringes. The number of needle pass attempts never exceeded three. A spirometry before biopsy was performed in all patients. RESULTS Pneumothorax occurred in only 10 cases (19%). The patients with pneumothorax showed lower lesion size, forced vital capacity (FVC), forced expiratory volume (FEV1), and FEV1/FVC ratio. The contribution of these factors to pneumothorax was analyzed by a logistic regression model. The FEV1 was most strongly associated with the incidence of pneumothorax. We developed an equation for predicting the risk of this complication. CONCLUSION We conclude that decreasing FEV1 is associated with a higher pneumothorax rate.

Tumor necrosis factor alpha as a marker of systemic and local inflammation in "healthy" smokers.

Background Tobacco smoking induces a local and systemic inflammatory reaction and also a decline in pulmonary function. There are some novel noninvasive methods to measure the degree of inflammatory bronchial reaction, including the exhaled breath condensate (EBC) in which several inflammatory markers can be measured, including tumor necrosis factor alpha (TNF-α). There is a clear clinical need to develop methods that allow early detection of smokers at risk of losing pulmonary function. Objectives The aims of the present study are: 1) to show that smokers show higher levels of TNF-α both in serum and EBC; 2) to analyze the possible influence of gender, age, and weight on this parameter; and 3) to determine a possible association between smoking and pulmonary function parameters and TNF-α levels. Material and methods We have prospectively analyzed two cohorts of smokers and non-smokers subjects without any chronic or acute disease (within eight weeks of study initiation). We have performed pulmonary function tests with bronchodilators and also collected EBC and blood samples before smoking cessation. Statistical analysis was performed with SPSS 11.0 for Windows Statistical Package. Results The study has enrolled 17 patients (8 smokers), 50% of whom were females. Mean age was 38.59 years old (standard deviation, 7.4). The mean number of cigarettes smoked in the smoker group was 26.14 (11.29) cigarettes/day and the mean age when tobacco first began was 15.14 (2.04) years. We have not been able to show any significant differences in TNF-α levels according to age or weight. For the whole series we have not found any significant influence of gender in TNF-α levels, but after dividing the series in smokers and nonsmokers, we have shown higher levels of TNF-α in serum (5.59 [0.26] pg/mL vs 5.56 [0.37] pg/mL; nonsignificant [NS]) and EBC (4.94 [0.41] pg/mL vs 4.22 [0.36] pg/mL; p = 0.031) in male smokers. On the other hand, nonsmoking females showed slightly higher TNF-α levels in serum (5.70 [0.50] pg/mL vs 5.42 [0.29] pg/mL; NS) and EBC (4.54 [0.92] vs 4.11 [0.41 pg/mL]; NS). Smokers had higher TNF-α levels in EBC (4.46 [0.58] pg/mL vs 4.34 [0.62] pg/mL; NS), while serum TNF-α levels were slightly higher in nonsmokers (5.52 [0.56] pg/mL vs 5.50 [0.27] pg/mL; NS). We have not demonstrated any association between tobacco consumption and TNF-α levels. We have not shown any significant relation between pulmonary function and the studied parameters, with only a modest association between forced expiratory volume at one second and forced vital capacity and TNF-α levels in EBC. Conclusion Smokers show higher TNF-α levels in EBC. Among smokers, males show higher levels of TNF in serum and EBC. We have not confirmed any significant influence of age or weight on TNF-α levels. These levels do not seem to be influenced either by the amount of tobacco or the time since habit began. We have shown a modest relation between pulmonary function and TNF-α levels in EBC.

Two full-term pregnancies in a patient with mitochondrial myopathy and chronic ventilatory insufficiency.

Mitochondrial myopathies are a group of diseases characterized by metabolic defects at the mitochondrial respiratory chain level which result in impaired oxidative phosphorylation and ATP synthesis. As with other neuromuscular diseases, respiratory muscles can be affected and ventilatory failure may occur. There have been isolated case reports of pregnant patients with ventilatory failure due to neuromuscular diseases such as polio and spinal muscular atrophy. We describe the case of a 34-year-old patient with mitochondrial myopathy and ventilatory failure requiring non-invasive ventilation who carried two pregnancies to term with no complications. We have not found a similar case in the literature.

Changing ventilator : An option to take into account in the treatment of persistent vomiting during nasal ventilation

Problems related with nasal intermittent positive pressure ventilation (NIPPV) are nasal and mouth dryness, soreness on the bridge of the nose, eye irritation and epistaxis. Gastrointestinal distention due to air swallowing has been reported in half of the patients. Acceleration of digestive function with drugs or reduction of the volume delivered to alleviate gastric distension are considered as the conventional treatment. It is also possible that the problem disappears spontaneously after a few weeks of NIPPV. We present a patient in whom conventional treatment was unsuccessful. When we changed to a different ventilator, symptoms disappeared, and the new one was very well tolerated. In our experience, changing ventilators should be included in the management of gastrointestinal distension due to NIPPV, especially if conventional procedures, such as drugs or gas flow modifications, fail.

High-Flow Nasal Cannula Can Be Used Outside the ICU

We read with great interest the article recently published in CHEST (July 2015) by Spoletini et al, 1 an excellent narrative review about the mechanisms of action and clinical implications of using heated, humidifi ed highfl ow nasal cannula (HFNC) oxygenation systems in adults. In their article, the authors make the recommendation that HFNC use on regular wards should be discouraged, especially in patients with severe hypoxemia. However, we do not entirely agree with this comment.