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ABSTRACT: Lung cancer is the leading cause of cancer mortality worldwide. A lack of clinical symptoms in early-stage disease frequently leads to diagnosis at a late stage, and a 15% 5-year survival rate in all patients so diagnosed. This has led to significant interest in effective screening methods to detect early-stage cancers, particularly for high-risk groups, such as current or former smokers. Early clinical trials focused on chest radiograph with or without sputum cytology and failed to show an improvement in mortality with screening. A meta-analysis also failed to show a difference in all-cause mortality. Subsequent protocols compared low-dose computed tomography (LDCT) scan with chest radiograph and documented increased detection of early-stage disease; however, they were not designed to prove a reduction in mortality. The most recent trials have focused on LDCT scans, including the National Lung Screening Trial. Data released from the National Lung Screening Trial demonstrated a statistically significant reduction in lung cancer deaths in patients screened with LDCT scans. When data from the study, including cost-effectiveness, are completely analyzed, they may lead to revision of current lung cancer screening recommendations to include LDCT scans in specific populations at high risk of developing lung cancer.
Hospital practice (1995). 11/2011; 39(4):107-12.
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ABSTRACT: Malignant pleural effusions (MPEs) affect > 150,000 people each year in the United States. Current palliative options include pleurodesis and placement of an indwelling catheter, each with its own associated benefits. This study was conducted to determine the safety, efficacy, and feasibility of a rapid pleurodesis protocol by combining medical thoracoscopy with talc pleurodesis and simultaneous placement of a tunneled pleural catheter (TPC) in patients with symptomatic MPE.
Patients with recurrent, symptomatic MPEs underwent medical thoracoscopy with placement of a TPC and talc poudrage. The TPC was drained per protocol until the output was < 150 mL/d on two consecutive drainage attempts and then removed. Patients were followed for up to 6 months.
Between October 2005 and September 2009, 30 patients underwent the procedure. The median duration of hospitalization following the procedure was 1.79 days. All patients showed an improvement in dyspnea and quality of life. Pleurodesis was successful in 92% of patients, and the TPC was removed at a median of 7.54 days. Complications included fever (two patients), the need for TPC replacement (one patient), and empyema (one patient).
Rapid pleurodesis can be achieved safely by combining medical thoracoscopy and talc poudrage with simultaneous TPC placement. Both hospital length of stay and duration of TPC use can be reduced significantly as compared with historical controls of either procedure alone. Future randomized trials are needed to confirm these results.
Chest 10/2010; 139(6):1419-23. · 5.25 Impact Factor
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ABSTRACT: Pulmonary alveolar proteinosis (PAP) is a disease characterized by the deposition of amorphous lipoproteinaceous material in the alveoli secondary to abnormal processing of surfactant by macrophages. Whole-lung lavage often is performed as the first line of treatment for this disease because it is a means to wash out the proteinaceous material from the alveoli and reestablish effective oxygenation and ventilation. Whole-lung lavage is a large-volume BAL that is performed mainly in the treatment of PAP. In brief, it involves the induction of general anesthesia followed by isolation of the two lungs with a double-lumen endotracheal tube and performance of single-lung ventilation while large-volume lavages are performed on the nonventilated lung. Warmed normal saline solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung, chest physiotherapy is performed, then the proteinaceous effluent is drained with the aid of postural positioning. The sequence of events is repeated until such time as the effluent, which is initially milky and opaque, becomes clear. This procedure results in significant clinical and radiographic improvement secondary to the washing out of the proteinaceous material from the alveoli. The whole-lung lavage video details all aspects of the procedure, including case selection, patient preparation and equipment, a step-by-step review of the procedure, and postoperative considerations.
Chest 12/2009; 136(6):1678-81. · 5.25 Impact Factor
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ABSTRACT: Bronchoscopic procedures to ablate endobronchial lesions (EBL) from renal cell carcinoma (RCC) are frequently complicated by hemorrhage because of the vascular nature of the metastases. After ablation, recurrence of symptoms from the EBLs is common. Photodynamic therapy (PDT), because of its mode of action, may be a safer and a more effective alternative in the nonemergent management of EBL from RCC.
Medical records of patients undergoing PDT at the authors' institutions between December 2005 and December 2008 were reviewed and patients undergoing treatment for EBLs from RCC were identified. Procedure-related complications, 30-day mortality, and efficacy of PDT measured by recurrence in symptoms and the need for additional interventions on the treated EBLs were reviewed.
Eleven patients underwent a total of 13 treatments with PDT. Hemoptysis, with or without symptomatic airway obstruction, was the most common presenting symptom. The most common location for the EBLs was the lobar or segmental bronchi. Six patients had undergone other interventions (rigid bronchoscopy, mechanical debridement, or argon plasma coagulation) before treatment with PDT, with recurrence in symptoms. No immediate complications were seen with PDT and none of the patients had recurrence of symptoms or required airway interventions during the 30-day follow-up. Four patients died at a median of 4 months (range: 3 to 6 mo) after PDT and all deaths were due to progression of cancer and none of the deaths were due to airway complications.
PDT is a safe and effective option for the management of hemoptysis or airway obstruction caused by EBLs from RCC.
Journal of bronchology & interventional pulmonology. 10/2009; 16(4):245-9.
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Chakravarthy Reddy
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ABSTRACT: Airway smooth muscles of asthmatics tend to be hyperresponsive when provoked. The exaggerated bronchial constriction can be measured by the airflow limitation seen following bronchial provocation. Measuring bronchial hyperresponsiveness by broncho provocation testing is helpful in diagnosing and optimizing therapy. While numerous agents have been used to provoke a measurable airflow limitation, standardized protocols are available for only a few. This article aims to discuss the various methods that have been reported for bronchoprovocation testing.
Clinical Reviews in Allergy & Immunology 04/2009; 37(3):167-72. · 3.68 Impact Factor
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ABSTRACT: Thermal ablation using argon plasma coagulation (APC) is a commonly used modality in the bronchoscopic management of central airway obstruction and hemoptysis. In experienced hands, APC is considered to be a relatively safe tool. Reported complications associated with APC use are rare and include hemorrhage, airway perforation, or airway fires. Systemic gas embolism has been reported with APC during laparoscopic hepatic surgeries, and we have reported one case of systemic gas embolism with cardiovascular collapse in the past. We now report the first case series of systemic, life-threatening gas embolism occurring as a complication of bronchoscopic application of APC.
Chest 12/2008; 134(5):1066-9. · 5.25 Impact Factor
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ABSTRACT: To assess the prevalence and characteristics of airway involvement in relapsing polychondritis (RP).
Retrospective chart review and data analysis of RP patients seen in the Rheumatology Clinic and the Complex Airway Center at Beth Israel Deaconess Medical Center from January 2004 through February 2008.
RP was diagnosed in 145 patients. Thirty-one patients had airway involvement, a prevalence of 21%. Twenty-two patients were women (70%), and they were between 11 and 61 years of age (median age, 42 years) at the time of first symptoms. Airway symptoms were the first manifestation of disease in 17 patients (54%). Dyspnea was the most common symptom in 20 patients (64%), followed by cough, stridor, and hoarseness. Airway problems included the following: subglottic stenosis (n = 8; 26%); focal and diffuse malacia (n = 15; 48%); and focal stenosis in different areas of the bronchial tree in the rest of the patients. Twelve patients (40%) required and underwent intervention including balloon dilatation, stent placement, tracheotomy, or a combination of the above with good success. The majority of patients experienced improvement in airway symptoms after intervention. One patient died during the follow-up period from the progression of airway disease. The rest of the patients continue to undergo periodic evaluation and intervention.
In this largest cohort described in the English language literature, we found symptomatic airway involvement in RP to be common and at times severe. The nature of airway problems is diverse, with tracheomalacia being the most common. Airway intervention is frequently required and in experienced hands results in symptom improvement.
Chest 12/2008; 135(4):1024-30. · 5.25 Impact Factor
