Viboon Boonsarngsuk

Acute respiratory failure due to Pneumocystis pneumonia: outcome and prognostic factors.

OBJECTIVES To examine the outcome and prognostic factors of in-hospital mortality in patients with acute respiratory failure (ARF) caused by Pneumocystis pneumonia (PCP) admitted to a medical intensive care unit. METHODS A retrospective review was conducted of all patients with ARF from PCP in Ramathibodi Hospital between 2000 and 2006. Patient characteristics, clinical presentation, and laboratory, radiological and microbiological findings, as well as therapy and clinical course were included in the analysis of prognostic factors of death. RESULTS A total of 14 HIV-infected and 30 otherwise immunosuppressed patients were identified. The overall mortality rate was 63.6%. Logistic regression analysis demonstrated that APACHE II score on day 1 and level of PEEP used on day 3 of respiratory failure were associated with higher hospital mortality. In a comparison between the HIV group and the non-HIV group, the early mortality rate was significantly higher in the HIV group, but late hospital mortality was not different between the two groups. Using a univariate logistic regression model, four parameters were found to be significantly associated with death in the HIV group: sex, APACHE II score on day 1, CMV co-infection, and level of PEEP on day 3 of ARF. In the non-HIV group, corticosteroid use prior to diagnosis of PCP and level of PEEP on day 3 of ARF were found to be the significant parameters. CONCLUSION The mortality rate in patients with ARF caused by PCP was high. Various variable factors were related to a poor prognosis. For improved survival, multimodality treatments are needed to reduce these risk factors.

Screening of Obstructive Sleep Apnea during Pregnancy: Differences in Predictive Values of Questionnaires across Trimesters

STUDY OBJECTIVES Evaluation of Berlin and Stop-Bang questionnaires in detecting obstructive sleep apnea (OSA) across trimesters of pregnancy. METHODS Pregnant women from a high-risk pregnancy clinic were recruited to complete sleep evaluations including Berlin and Stop-Bang Questionnaires. Overnight testing with Watch-PAT200 for diagnosis of OSA (cutoff point of apnea-hypopnea index ≥5 events/h) was performed. RESULTS Seventy-two singleton pregnant women participated in the study. Enrollment consisted of 23, 24, and 25 women during first, second, and third trimesters, respectively. Of 72 pregnancies, 23 patients (31.9%) had OSA. Prevalence of OSA classified by trimesters from first to third was 30.4%, 33.33%, and 32.0%, respectively. Overall predictive values of Berlin and Stop-Bang questionnaires were fair (ROC area under curve, AUC 0.72 for Berlin, p = 0.003; 0.75 for Stop-Bang, p = 0.001). When categorized according to trimesters, predictive values substantially improved in second (AUC: 0.84 for Berlin; 0.78 for Stop-Bang) and third trimesters (AUC: 0.81 for Berlin; 0.75 for Stop-Bang), whereas performances of both questionnaires during first trimester were poorer (AUC: 0.49 for Berlin; 0.71 for Stop-Bang). Multivariate analyses show that pre-pregnancy body mass index (BMI) in first trimester, snore often in second trimester, and weight gain and pregnancy BMI in third trimester were significantly associated with OSA. CONCLUSIONS In high-risk pregnancy, Berlin and Stop-Bang questionnaires were of limited usefulness in the first trimester. However their predictive values are acceptable as pregnancy progresses, particularly in second trimester. OSA in pregnancy seems to be a dynamic process with different predictors association during each trimester.

Combination of adenosine deaminase activity and polymerase chain reaction in bronchoalveolar lavage fluid in the diagnosis of smear-negative active pulmonary tuberculosis

BACKGROUND Some studies have assessed the diagnostic value of adenosine deaminase (ADA) activity in bronchoalveolar lavage fluid (BALF) in the diagnosis of pulmonary tuberculosis (TB). However, a conclusion has not been reached due to the limited number of patients with various pulmonary diseases used as comparators. The objective of this study was to evaluate the efficacy of BALF ADA activity and TB PCR assay for diagnosing pulmonary TB. METHODS BAL samples from 424 patients with acid-fast bacillus-negative sputum smears who underwent bronchoscopy for diagnostic evaluations of pulmonary diseases, were prospectively analyzed for ADA activity and TB PCR. RESULTS The median ADA activity of TB cases was significantly different from that of patients with solid tumor without endobronchial obstruction (p<0.001), inactive TB (p=0.04), and other (p=0.038), while this was not the case for the other pulmonary diseases. A cutoff BALF ADA activity of ≥3 U/l provided a sensitivity of 58.7% and specificity of 81.8% to differentiate TB from solid tumor without endobronchial obstruction. The sensitivity of TB PCR in BALF was 28.1% with a specificity of 99.0%. The area under the receiver operating characteristic (ROC) curve to differentiate TB from solid tumor without endobronchial obstruction was significantly higher for the combination of ADA activity ≥3 U/l and TB PCR (0.77) than for ADA activity ≥3 U/l alone (0.70, p<0.001) or for TB PCR alone (0.64, p<0.001). The sensitivity of the combination of ADA activity ≥3 U/l and TB PCR was 72.7% and the specificity was 81.8%. In TB cases, a greater radiographic extent of disease was associated with a higher median ADA activity (p=0.017). CONCLUSIONS BALF ADA had limited value in differentiating pulmonary TB from some other pulmonary diseases. To differentiate TB from solid tumor without endobronchial obstruction, a combination of BALF ADA and TB PCR had marked additive diagnostic value.

Primary polymorphous low-grade adenocarcinoma of the bronchus: Complete tumor removal with bronchoscopic resection

Primary polymorphous low-grade adenocarcinoma (PLGA) is an uncommon malignant tumor arising from the minor salivary glands, but its occurrence as a primary tumor of the tracheobronchial tree is very rare. Herein, we have reported a rare case of endobronchial PLGA in a 56-year-old woman presenting with chronic cough and progressive exertional dyspnea. Chest CT clearly demonstrated an endobronchial tumor obstructing the distal part and bifurcation of the left main bronchus and causing distal atelectasis. She underwent rigid bronchoscope with electrocautery and bronchoscopic resection of the tumor. PLGA was diagnosed histologically. Subsequent left pneumonectomy was performed and showed no evidence of residual tumor.

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment.

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.

Comparison of diagnostic performances among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions

BACKGROUND There are many sampling techniques dedicated to radial endobronchial ultrasound (R-EBUS) guided flexible bronchoscopy (FB). However, data regarding the diagnostic performances among bronchoscopic sampling techniques is limited. This study was conducted to compare the diagnostic yields among bronchoscopic sampling techniques in the diagnosis of peripheral pulmonary lesions (PPLs). METHODS A prospective study was conducted on 112 patients who were diagnosed with PPLs and underwent R-EBUS-guided FB between Oct 2012 and Sep 2014. Sampling techniques-including transbronchial biopsy (TBB), brushing cell block, brushing smear, rinsed fluid of brushing, and bronchoalveolar lavage (BAL)-were evaluated for the diagnosis. RESULTS The mean diameter of the PPLs was 23.5±9.5 mm. The final diagnoses included 76 malignancies and 36 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 80.4%; TBB gave the highest yield among the 112 specimens: 70.5%, 34.8%, 62.5%, 50.0% and 42.0% for TBB, brushing cell block, brushing smear, rinsed brushing fluid, and BAL fluid (BALF), respectively (P<0.001). TBB provided high diagnostic yield irrespective of the size and etiology of the PPLs. The combination of TBB and brushing smear achieved the maximum diagnostic yield. Of 31 infectious PPLs, BALF culture gave additional microbiological information in 20 cases. CONCLUSIONS TBB provided the highest diagnostic yield; however, to achieve the highest diagnostic performance, TBB, brushing smear and BAL techniques should be performed together.

Diagnóstico de lesiones pulmonares periféricas con broncoscopia bajo guía de ecografía endobronquial radial

INTRODUCTION The diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists. Radial probe endobronchial ultrasound (R-EBUS) has been developed to enhance diagnostic yield. The objective of this study was to evaluate the effectiveness of R-EBUS in the diagnosis of PPLs. METHODS A retrospective study was conducted on 174 patients diagnosed with PPLs who underwent EBUS-guided bronchoscopy. Histological examination of specimens obtained by transbronchial lung biopsy (TBLB) and cytological examinations of brushing smear, brush rinse fluid and bronchoalveolar lavage fluid (BALF) were evaluated for the diagnosis. RESULTS The mean diameter of the PPLs was 25.1 ± 10.7 mm. The final diagnoses included 129 malignancies and 45 benign lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 79.9%. Neither size nor etiology of the PPLs influenced the diagnostic performance of EBUS-guided bronchoscopy (82.9% vs. 74.6% for PPLs>20mm and PPLs≤20mm; p=0.19, and 82.9% vs. 71.1% for malignancy and benign diseases; p=0.09). TBLB rendered the highest yield among these specimens (69.0%, 50.6%, 42.0%, and 44.3% for TBLB, brushing smear, brush rinse fluid, and BALF, respectively; p<0.001). The combination of TBLB, brush smear, and BALF provided the greatest diagnostic yield, while brush rinse fluid did not add benefits to the outcomes. CONCLUSION R-EBUS-guided bronchoscopy is a useful technique in the diagnosis of PPLs. To achieve the highest diagnostic performance, TBLB, brushing smear and bronchoalveolar lavage should be performed together.

Endobronchial ultrasound-guided transbronchial needle aspiration rinse fluid polymerase chain reaction in the diagnosis of intrathoracic tuberculous lymphadenitis

Abstract Background: Intrathoracic tuberculous (TB) lymphadenitis is a diagnostic challenge to the clinician. Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can obtain a sample from the affected lymph node, the diagnosis of TB lymphadenitis by cytopathology remains inaccurate. Objective: To evaluate the efficacy of EBUS-TBNA rinse fluid TB polymerase chain reaction (PCR) assay for the diagnosis of intrathoracic TB lymphadenitis. Methods: A retrospective study was conducted on 102 patients who underwent EBUS-TBNA for diagnostic evaluation of intrathoracic lymphadenopathy. EBUS-TBNA specimens were evaluated by cytopathological examination. Rinse fluid of the needle was routinely submitted for acid-fast bacillus (AFB) staining, mycobacterial culture, and TB-PCR using the AnyplexTM MTB/NTM real-time detection kit. Results: Of 102 patients, 16 were diagnosed with intrathoracic TB lymphadenitis by either microbiology, cytopathology, or on clinical grounds. The sensitivity, specificity, positive predictive value, and negative predictive value of rinse fluid TB PCR assay were 56.2%, 100.0%, 100.0%, and 92.5%, respectively. Using the area under the ROC curve (AUC) as a measure of a diagnostic performance, TB-PCR had the highest AUC, compared with mycobacterial culture, AFB smear, and finding of necrotizing granulomatous inflammation (0.78, 0.75, 0.56, and 0.72, respectively). A combination of TB PCR, mycobacterial culture, and finding of necrotizing granulomatous inflammation provided the best diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value, and AUC of 75.0%, 100.0%, 100.0%, 95.6%, and 0.88, respectively). Conclusions: EBUS-TBNA rinse fluid TB-PCR is useful in the diagnosis of intrathoracic TB lymphadenitis. Combining TB-PCR with mycobacterial culture and cytopathological findings improved the diagnosis performance.

Puzzling Bronchial Trifurcation

Unexpected and puzzling variations in bronchial anatomy might be discovered during bronchoscopy. The occurrence of congenital tracheobronchial anomaly is estimated to range between 1% and 12% of the overall population.[1][1] We present 2 rare cases of congenital bronchial anomaly that were

Autoaspiration versus manual aspiration in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy.

BackgroundTraditionally, aspiration with high negative pressure is recommended to obtain a specimen in transbronchial needle aspiration (TBNA). Undeniably, however, the assistant experiences difficulty in the generation of the negative pressure and precise control of the syringe while performing the procedure. ObjectiveTo evaluate the effectiveness of the autoaspiration method created by our plunger lock in comparison with the conventional manual aspiration in the diagnosis of intrathoracic lymphadenopathy by TBNA. MethodsA prospective study was conducted on all patients referred for diagnostic TBNA of enlarged intrathoracic lymph nodes. Both automatic and manual aspiration techniques were performed after the needle had been completely inserted into the nodes. The diagnostic yield and the numbers of diagnostic cells or benign lymphoid cells obtained by each technique were compared in the same node. ResultsA total of 31 intrathoracic lymph nodes in 24 patients were prospectively studied. Twenty-four nodes (77.4%) were malignancies whereas 7 nodes (22.6%) were benign disease. Adequate lymph node samples were obtained in 30 targets (96.8%), and TBNA revealed definite diagnosis for 25 nodes (80.6%). Both aspiration techniques showed exactly the same diagnostic yield. However, the autoaspiration technique provided significantly more adequate samples than manual aspiration techniques did (P=0.003). ConclusionThe autoaspiration method using our plunger lock was superior to the manual method in obtaining the numbers of adequate samples in TBNA procedures.