Evaluation Of Pulmonary Abnormalities Research Articles

Evaluation of pulmonary abnormalities in recipients of hematopoietic cell transplants and cellular therapies.

Hematopoietic cell transplant (HCT) and chimeric antigen receptor T-cell (CAR-T) therapy recipients are susceptible to multiple pulmonary complications that are caused by infectious and noninfectious processes. Numerous variables can be associated with specific pulmonary diseases including time from transplantation, presence of graft versus host disease (GVHD), underlying disease, and prolonged neutropenia and lymphocytopenia. Most pulmonary complications are infectious in origin, with bacterial pneumonia remaining the most common pulmonary infection, particularly before neutrophil engraftment. Invasive fungal infections continue to affect this patient population even when antifungal prophylaxis is used. Noninfectious pulmonary complications include a wide differential of pathologies in this population, and as clinical presentations of these various pulmonary disorders often overlap, clinicians frequently will use a multidisciplinary approach in diagnosing these abnormalities. Radiography, particularly with chest computed tomography (CT) imaging, is an essential tool in identifying pulmonary pathology and potential sources. While standard microbiological cultures of respiratory specimens are still utilized, their role is limited by low sensitivity and diagnostic yield. The likelihood of obtaining a diagnosis can be improved by using other microbiological assays, including fungal antigen tests and molecular diagnostic methods, particularly if specimens are collected via bronchoscopy. This review will highlight the more common causes of pulmonary diseases encountered after HCT and CAR-T and will examine the different methods in their diagnosis.

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Introduction: Pediatric flexible bronchoscopy has become increasingly important in the evaluation of pulmonary abnormalities in children. Sedating such patients has become standard care with the hope of improving the success and tolerance of these procedures. Our intensivist-based procedural sedation team has assisted pulmonologists to sedate children with flexible bronchoscopy. We hypothesized that our team delivers care which safely and effectively facilitates the successful completion of this procedure. Methods: Retrospective chart review of all sedations performed from 2007 to 2011 for flexible bronchoscopy. These procedures occurred in an outpatient hospital-based setting. Procedural sedations consist of either a propofol only approach or one using ketamine premedication(0.5mg/kg for < 20 kg patients or 0.25mg/kg for patients > 20kg) followed by propofol. Demographics, sedative dosing, sedation and recovery time, interventions and adverse events were reviewed. Results: 508 procedures were performed. Average patient age was 6.07 y (range 0.17-16.98y). 99% of the procedures were successfully completed. Four cases (two toddlers and two adolescents) were stopped early due to recalcitrant hypoxemia where two patients were admitted to the pediatric intensive care unit. One of the four patients required intubation and two fluid boluses. Mild transient hypoxemia and hypotension occurred in 8% and 24% of the patients. Most patients (92%) received O2 via NC and few (4%) required brief BMV. Average procedure time was 11 min and the average time to discharge was 37 min. Propofol alone was used in 396 (78%) and 112 (22%) had ketamine pre-treatment. There were no differences in propofol dose (4.3 and 4.1 mg/kg respectively), complications or recovery time based on sedative regimen. Conclusions: Children can be safely sedated for flexible fiberoptic bronchoscopy via an intensivist-run sedation team in an exam room setting with expediency and a high rate of success. Under the vigilance of a highly trained group practice in pediatric respiratory and cardiovascular monitoring and management, there were few unanticipated sequel. There may be economic and workflo advantages to this appropoach.

The role of flexible fibreoptic bronchoscopy in evaluation of pulmonary diseases in children with congenital cardiac disease

Diseases of the lungs and airways can be life-threatening in patients with congenital cardiac disease. External compression, and tracheobronchomalacia, as well as pathology of the large airways, can cause respiratory symptoms such as wheezing, stridor, fever, and dyspnoea, along with producing difficulty to wean the patient from mechanical ventilation. A definite diagnosis may be achieved by fibreoptic flexible bronchoscopy. To characterize the patients who underwent bronchoscopy for respiratory diseases associated with congenital cardiac disease, and to evaluate the safety, total diagnostic rate, and diagnostic rate, which yielded alteration of treatment in this group of patients. We reviewed retrospectively the records of 39 patients with congenital cardiac disease associated with abnormalities of the airways who underwent 49 fibreoptic bronchoscopies between 1999 and 2004. The patients were evaluated with regard to rate of diagnosis, the rate of procedures that resulted in alteration of management, and the rate of complications. Fibreoptic flexible bronchoscopy was safe, and contributed to a specific diagnosis in almost nine-tenths of the procedures. A specific diagnosis that resulted in treatment alteration was achieved in one-fifth of the procedures. Fibreoptic flexible bronchoscopy has an important role in the evaluation of pulmonary abnormalities in patients with congenital cardiac diseases, and should be considered as an initial diagnostic tool that may guide the clinician with regard to the proper therapy.

111. Evaluation of pulmonary abnormalities in adult patients with cystic fibrosis through the comparison of HRCT with pulmonary function tests

111. Evaluation of pulmonary abnormalities in adult patients with cystic fibrosis through the comparison of HRCT with pulmonary function tests

Fiberoptic Bronchoscopy in Coronary Care Unit Patients: Indications, Safety, and Clinical Implications

To evaluate the indications, safety, therapeutic impact, and outcome of fiberoptic bronchoscopy (FOB) in coronary care unit (CCU) patients. Retrospective review of all CCU patients undergoing FOB during a 6-year period. Tertiary care university hospital. Among 8,330 patients admitted to the CCU; 40 (0.5%) patients underwent FOB to evaluate pulmonary abnormalities, most often (78%) to appraise clinically suspected pneumonia. Thirty-five (88%) patients were intubated and 21 (53%) had acute myocardial infarction (MI) before FOB. There were two major complications (bleeding, intubation) occurring within 24 h of FOB, one of which appeared due to the procedure. No episodes of chest pain or ischemic events were recorded and no significant increase in major complications was noted in MI patients (3% vs 5%). Patients having FOB within 10 days of MI had higher survival (79%) than those undergoing FOB later (29%) (p = 0.05). Seven different bacterial pathogens were isolated in 6 (15%) patients, probably reflecting prior empiric antibiotics in 32 (80%) patients. Therapy was changed in 64% of patients in whom a potential pathogen was identified. Despite alterations in treatment, patients with clinically suspected pneumonia and any organisms isolated by FOB had greater mortality (79% vs 31%, p = 0.003) than those with sterile FOB cultures. FOB may be diagnostically useful in the evaluation of pulmonary abnormalities in selected patients with acute cardiac disease, can be performed safely, and may influence management decisions. Positive bronchoscopy cultures often influence therapy but are associated with higher mortality, suggesting a lethal effect of nosocomial pneumonia in this subset of CCU patients. The risks of FOB must be weighed with the impact of FOB results on patient outcome, and its role requires further investigation.

The significance of alterations in the lung arterial pattern.

Aknowledge of the arterial blood supply to the lungs, which can be determined by standard radiographic methods, may be helpful in establishing their physiologic status. Classical pulmonary function tests, such as the determination of vital capacity, maximal breathing capacity, and timed vital capacity, only measure ventilation; they do not evaluate perfusion of the lungs. A localized deficiency in ventilation is measured only as a total deficit in function by these methods unless a complicated technic such as bronchospirometry is used. The information about the lung circulation which is obtained by the radiographic procedures to be described, interpreted on the basis of well accepted pathophysiologic data, will aid in the evaluation of pulmonary abnormalities and in the selection of patients for surgical treatment. Material In order to demonstrate the clinical usefulness of such information, venous and aortic angiography was performed in dogs after the pattern of blood supply to the lungs had been altered in three ways: 1. By transection and suture of a main bronchus (Fig. 1), which has been shown to diminish the pulmonary artery blood supply to the atelectatic lung without any increase in the bronchial collateral circulation(1). When studies were completed at this stage, some of the animals were operated on a second time and the transected bronchus was anastomosed; this was done twelve to twenty-four months after the initial transection. 2. By ligation of a main pulmonary artery, which leads to the development of extensive bronchial arterial collateral circulation. 3. By anastomosis of the left subclavian artery to the pulmonary artery (Blalock procedure) (Fig. 2). This simulates the pulmonary plethora seen with left-to-right shunts and provides an easily demonstrable systemic-pulmonary artery anastomosis. After completion of the radiographic studies, autopsies were performed on some of the animals, followed by plastic and barium injection studies, in order to verify anatomically the impressions gained from the films. Radiologic Findings In animals in which a bronchus had been transected, there was a prompt collapse of the lung, accompanied by a shift of the mediastinum toward that side. This was associated with increased expansion of the normal lung, which soon became distended enough to occupy almost all of the chest. Aortograms revealed no filling of the bronchial arteries on either side under these conditions of chronic atelectasis (Fig. 3). Venous angiography (Fig. 4, A) provided good visualization of the pulmonary arteries on the unoperated side of the chest. In addition, these vessels were two or three times larger than normal and were widely spread, as would be expected from the compensatory overexpansion of the normal lung.