Occurrence of Mitral Valve Prolapse in Nonsmoker Spontaneous Pneumothorax Patients

pleuroscopy Hover conventional means of diagnosis is unclear" is virtually impossible to draw from the paper of Faurschou et ale Pleuroscopy deserves, indeed, more attention. Since 1910, 2 pleuroscopy has been widely used, mainly in Europe, as a diagnostic and therapeutic procedure. Its diagnostic yield in pleural effusion is close to 100 percent. u Pleuroscopy is usually perfonned with the use of local anesthesia and, although it requires hospitalization, has several advantages over closed pleural biopsy: (1) It allows examination of the pleural cavity, including the costal pleura, the diaphragmatic dome, the cardiophrenic and costophrenic angles, the lung surface and fissural aspects of the lobes, and the mediastinal pleura. (2) Pleural biopsies can be taken at multiple sites under visual control. (3) Lung biopsies can be taken easily.7.8 (4) Instillation of sclerosing agents for chemical pleurodesisl·9 can be done at the end of the procedure if a frozensection biopsy yields a positive result for malignancy. Complications of pieuroscopy, such as subcutaneous emphysema, shortness of breath, and arrhythmias, are observed in less than 10 percent of the patients. 10 Mortality is minimal: only one death was found in a review ofapproximately 8,000 diagnostic pleuroscopic procedures. 10 We believe that, if the same diseases can cause both symptomatic and asymptomatic pleural effusions (as Smyrnios et al concluded), a more active diagnostic workup should be established, especially to rule out malignancy and tuberculosis. Therefore, pleuroscopywhich is clearly superior to repeated pleural 8uid CYtology and blind pleural biopsys-should be considered when a thoracentesis with closed pleural biopsy has not been diagnostic and the probable cause of the effusion is not clinically apparent. RamOn Rami-Porta, M.D.; jose Luis Heredia, M. D.; Miguel Cuesta, M.D.; Lucia Ortega, M.D.; and Isabel Mir, M.D., Departments of Thoracic Surgery and Pneumology, Hospital Mutua ck Terrassa, Terrassa (Barcelona), Spain

To the Editor:

We read with interest the letter by Rami-Porta et aI <.:on<.-erning the limited discussion of pleuroscopy in our recent special report on the evaluation of asymptomatic pleural effusion. Our bias in favor of a second closed biopsy stems from our own limited experience with pleuroscopy and the less-than-definitive literature on the comparcltive usefulness of pleuroscopy. We disagree with the statement that pleuroscopy has been ··widely used" since 1910. Most studies of pleuroscopy are retrospective series in which the diagnostic yields of thoracentesis and closed pleural biopsy have not been compared with pleuroscopy in a formal way.I.2 However, Boutin et a13 employed a more systematic analysis of the sensitivity of these different methods and found that pleuroscopy resulted in 84 percent positive results in 75 patients with mali~ant pleural effusion who had three previous negative cytologic and two previous negative needle biopsy results. There is little doubt that the procedure can be useful for some indications, as noted by Rami-Porta et a1. To these we would also add its use to avoid unnecessary thoracotomy and when tube thoracostomy will be required anyway. On the other hand, ne~tive aspects of pleuroscopy include the need for an average hospitalization of three to four days, which is an important (.'Onsideration these days. l.4 General anesthesia is used by some advocates, with its associated risk. 3 There is also the morbidity associated with the need for prolonged chest tube drainage after the pnx:edure. Complications reported include hemorrhage, subcutaneous emphysema, bronchopleural fistula, tumor seeding, persistent pneumothorax, and death. However, the frequency of complications is less than that seen with open pleural biopsy or open lung biopsy, a point in favor of pleuroscopy. We agree that the use of pieuroscopy in select cases with local anesthesia can be helpful in evaluating the cause of pleural effusion. A more widespread role can be defined only by prospective studies comparing its risks and benefits with those of other diagnostic studies. Nicholas A. S1l1yrnios, M. D. , lMer J lederlinic, M.D., F.C.C.l, and Richard S. Irwin, M.D., f~C.C.l, Deparltllent of Medici rae , University of Massachusetts, Worcester

Reprint requests: Dr Rami-Porta, Calle Santa Filomena 3, 08017 Barcelona, Spain REFERENCES

1 Faurschou ~ Madsen F, Viskum K. Thoracoscopy: influence of the procedure on some respiratory and cardiac values. Thorax 1983; 38:341-43 2 Jacobaeus HC. Ueber die MOglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Munch Med Woch 1910; 40:2090-92 3 Weissberg D, Kaufman M. Diagnostic and therapeutic pleuroscopy: experience with 127 patients. Chest 1980; 78:732-35 4 Miller JI, Hatcher CR Jr. Thoracoscopy: a useful tool in the diagnosis of thoracic diseases. Ann Thorac Surg 1978; 26:68-72 5 Boutin C, Viallat JR, Cargnino ~ Farisse ~ Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:58892 6 Rodgers BM, Ryckman FC, Moazam F, Talbert JL. Thoracoscopy for intrathoracic tumors. Ann Thorac Surg 1981; 31:41420 7 Boutin C, Viallat JR, Cargnino ~ Rey F. Thoracoscopic lung biopsy: experimental and clinical preliminary stud~ Chest 1982; 82:44-48 8 Dijkam JH, van der Meer JWM, Bakker W, Wever AMJ, van der Broek PJ. Transpleural lung biopsy by the thoracoscopic route in patients with diJruse interstitial pulmonary disease. Chest 1982; 82:76-83 9 Cant6 A, Rivas J, Saumench J, Morera R, Moya J. Points to consider when choosing a biopsy method in cases of pleurisy of unknown origins. Chest 1983; 84:176-79 10 Viskum K, Enk B. Complication of thoracoscopy. Poumon Coeur 1981; 37:25-28

REFERENCES

1 Weissberg D, Kaufman M. Diagnostic and therapeutic pleuros<.'Opy: experience with 127 patients. Chest 1980; 78:732-35 2 Miller JI, Hatcher CR. Thoracoscopy: a useful tool in the diagnosis of thoracic disease. Ann Thorac Surg 1978; 26:68-72 3 Boutin C, Viallat J8, Cargnino ~ Farisse ~ Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:588-92 4 Dijkam JU, Vandermeer JWM, Bakker W, Wever AMJ, VanderBrock PJ. Transpleural lung biopsy by the thoracoS<.'Opic route in patients with diJruse interstitial pulmonary disease. Chest 1982; 82:76-83

Occurrence of Mitral Valve Prolapse In Nonsmoker Spontaneous Pneumothorax Patients 1b the Editor:

MargaIiot et all found mitral valve prolapse (MVP) in 11 of 22 (50 percent) patients who suffered spontaneous pneumothorax (SP) but in only 10 percent (four of 40) of the control subjects. They concluded that the excessive occurrence of MVP is the first documented proofof connective tissue disease, an underlying factor in the development ofS~ CHEST I 99 I 3 I MARCH, 1991

791

They presented no data on smoking habits for either the SP patients or the control subjects. Smoking has statistically been shown to increase the risk of contracting S~2 For this reason, we studied the occurrence of MVP in ten SP patients who had never smoked, with the same method. These patients were randomly selected from the group of SP patients who had never smoked and who were treated/controlled at the Department of Pulmonary Medicine, Huddinge University Hospital, in 1980-1989. The diagnosis of MVP could be established in one patient. may colnplete the data presented by Margaliot et al This findin~ and suggests that smoking may have some role in the hitherto unclarified pathogenetic mechanism of MV~

Usuo Bense, M.D., Ph.D.,

f~C.C.R;

OlofEdhag, M.D., Ph.D.; Gunnar Eklund, He, M.D., Ph.D., Odont.D.; and Karl- Erik Karlberg, M. D., Huddinge University Hospital, Karolitlska Institute, Stockhol,n, Sweckn

Reprint requests: Dr Bense, Postangsv232, 14552 Norsborg, Sweden

REFERENCES 1 Margaliot SZ, Barzilay J. Ba....David M. Lewis BS. Froom ~ Forecast D, Gross M. Spontaneous pneumothorax and Initral valve prolapse. Chest 1986; 89:93-94 2 Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987; 92:100912

Tracheobronchial Stents and Fiberoptic Bronchoscopy To the Editor: We read with interest the article by OUlnon (Chest 1990; 97:32S32), regarding a specific tracheobn)nchial stent. The author states that &Cinsertion requires rigid bronchoscopy with the patient under general anesthesia." Recently, we had the opportunity of inserting one of these prostheses designed by Dumon using a fiberoptic bronchoscope (FB). A 42-year-old man with a large-cell undifferentiated carcinOOla of the right upper lobe and extrinsic compression of the bronchus intennedius underwent explorative thoracotomy. In the following postoperative days, he required bronch06berscopic toilet repeatedly because of recurrent atelectasis of the right lower and middle lobes, We decided to insert a stent in the causing respiratory insufficien~ bronchus intennedius. This maneuver was performed by Ineans of an FB and with use of local anesthesia. The respirdtory symptoms were relieved with complete resolution of the atelectasis within 48 h. Three months later the patient's general state was satisfactory with excellent tolerance of the prosthesis. The insertion technique is simple. The FB (Fujinon BRO-Y-2S) is in effect sheathed within the upusher tube" (a 8exible, plastic, 45-5O-cm-Iong tube of the same diameter as the prosthesis to be inserted), leaving the last few centimeters free for the stent to be placed in such a way as to leave the FB totally covered by both tubes. The FB is introduced, sheathed as already described, and the stent is placed orclJly in the chosen site with direct visual control. This done, we remove both the FB and the upusher tube," confinning the ('Orrect placement of the stent and achievement of the intended solution. The most extensive experience with these stents until now· does not report the placement of this kind of prosthesis by means of an FB and with standard local anesthesia. Although this technique can

792

be applied only in certain cases and with slnall stents, using the above method makes this operation not only efficient but also easier, quicker, and practically risk free.

Section.~

f: Rodrigue;:, de Castro, M.D., IJ. LOpe;:" M.D., A. Varela, M.D., and J Freuinet, M.D., of Pneu,oology and Thoracic Surgery, Hospital Nuestra Se,1ora del Pi'lo, Uls IbII1Ul.-; de Gran Canaria, Spain I{EFERENCE

DUlllOIl JF. Une endoprothese tracheobronchique speci6que. Presse Med 1989; 18:2055-58

To the Editor: The fibers(,'opic technique ofstent insertion under local anesthesia des('ribed by Rodriguez de Castro et al is interestinJ( fi)r selected patients. The main lilllitation is location. Patients with unilaterclJ tulnors have a functional lung. and the danJ(er of acute da'Ompensation is ('Ontrollable. IIowever, in patients with tumors located in the trachea, the risk of severe hypoxia is nlllCh J.,'J'eater. The rigid system allows the bronchoS(.·opist to go through the tUlnor and establish an airway irnlnediately. Moreover, with the larger prostheof the v<)(.·al ("ords can he sis required in the trachea, passa~e traunlatic if the stent is not fc:)lded. On a Inore general level, I believe that the rigid systeln is more suited to ther&lpeutic endos(,'op): I agree that acrobatics with the fibers(,'Ope are always feasible, and I have even done some myself. However, the operator's ability to respond to certain (tomplications is also greatly irnpaired. If (,'olnplications occur or if it is necessary to reluove or reposition the prosthesis, the options are greatly liolited with the 8exible system. General anesthesia is an obstacle to the use of the rigid system in the rninds of many endos(,·opists. Specially equipped facilities and trained anesthetists are required. However, with nlodern techniques and drugs such as propofol, therapeutic endos(,'opy can be performed as a same-day proc-edure. Many bronchos(,topists oppose 6hers<..'Opy and rigid bronchoscopy. In fact, these two techniques are (,tomplementary. Nowadays, a puhnonary endos<..topist OlUSt be pro6cient in both. ]ean-FraRf0is Dumon, M.D., f:C.C.R, H6pital Sainte Marguerite, Marseille, France

Erratum To the Editor: We have a (,'Orrection for our article ·The Spectrum of Tuberculosis in a New York City Mens Shelter Clinic (1982-1988)" (Chest 1990; 97:798-8(5). The figure provided for the annual rate of cases of active tuberculosis for this population during the period study was in('Orrect. The (,'Orrect rate is 875/100,000. john M. McAdam, M.D., Att~nding

Physician,

Department ofC01n,nunity Medicine, St. Vincents Hospital and Medical Center, New York Communications to the Editor