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Pulmonary Diagnostic and Monitoring Techniques 10:30 AM – 11:20 AM
Monday, October 31, 1994 Pulmonary Diagnostic and Monitoring Techniques 10:30 AM - 11:20 AM Title: LUNG ELASTICITY IN DOUBLE LUNG TRANSPLANT
Author(s)c Licskat, N Zamel, J Maurer, University of Toronto, Toronto, Ontario To evaluate the effect of lung elasticity on PFT posttransplant, we analyzed 69 static compliance curves of 44 patients obtained between 3 & 18 months post double lung transplant (OL1). Pressure-volume points were fitted to the single exponential V=ABe-KP using the Marquardt-Levenberg algorithm (V=volume, P=pressure, A,B,K=constants). Mean R2=0.90. Mean maximum inspiratory pressure was 91 ±25. 7% predicted. TLC & FAC were not different from the donor or recipient predicted. The shape constant of the curve,K, is a volume independent measure of the retractive force of the lung between 50-100% TLC. Measured K approximated the donor predicted K and was lower than the recipient predicted. FEV1/FVCwas greater than recipient predicted and tended toward being higher than donor predicted. We conclude that DLTs receive donor lungs with higher than predicted elasticity. Despite this FAC is 94% of recipient predicted suggesting a coincident increase in chest wall recoil. The tendency toward FEV1/FVC > predicted donor flows suggests undersizing as an explanation for increased chest wall recoil. Cohort P < Donor Pred. Recip. Pred. P <
K
TLC(L) TLC(L) FRC(l)
.13837 ±.0114
75.9 ±2.8 5.59 ±.89 3.08 ±.53
.05
.003 ..91 .29
.12246 ±.0498 83.0 ±14.1 5.56 ±1.26 3.2~
±.72
NS
.08 N8
NS
.12716 ±.012
78.8 ±3.9 5.95 ±1.44 3.15 ±.74
POSITIVE EXPIRATORY PRESSURE THERAPY IN THE POST-OP CARE OF THE LUNG TRANSPLANT PATIENT . Jeffrey Tarnow, RRT*, & Michae~ Manlmeister, M~, RRT Author(s). Medical Center at the U. of California, San FranCISCO INTRODUCTION Following lung transplant, respiratory care is normally provided to maintain t~e l!se of lung expansion and facilitate secretion clearance, ~ncluding postural drainage and percussion (PD&P). We descnbe the application of an alternative bronchial hygiene technique, Positive Expiratory Pressure (PEP) therapy, in a series of 8 lung transplant patients. PEP is performed with the patient sitting up in bed. They inspire a slow maximum breath, perform a 3 second breath hold, then actively exhale through a fixed orifice A ser~es of resistor, creating an expiratory pressure between lO-~OcmH2~. 20-30 PEP breaths are performed, followed by coughmg to raise secreuons, METHODS Eight patients underwent single lung transplantation~ mean age 46 q4-5~). Diagnoses included COPD (5), pulmonary hypertension, alpha I anutrypsm deficiency, and pulmonary fibrosis. Following extubation patients received PEP therapy Q4 hours w/a & pm, along with Incentive Spirometry, plus aerosol bronchodilators pm. On ICU discharge, PEP was provided QID for a minimum of 3 days. then patients were evaluated for self-administration. RESULTS All 8 patients received PEP therapy Q4hours w/a in ICU. Post-K'U discharge, patients received therapist-administered PEP QID for an ave~age of 3.8 days, followed by transition to self-performed PE~. No 'pauent required additional therapy such as PD&P or IPPB dunng theI~ postoperative recovery, and no patient required return to ICU for resplfat~ry failure. No patient required bronchoscopy intervention for secreuon retention or atelectasis, and no patient had any complications from PEP therapy. Mean ICU stay was 5.1 days, mean hospital stay was 16.6 days. DISCUSSION PEP therapy represents a safe, effective alternative to PD&P in this patient population. Advantages include shorter treatment time c~mpare~ to PD&P and avoidance of adverse cardiopulmonary effects associated WIth PD&P. PEP can produce significant cost savings, since it can be self-administered. fw:ther studies are recommended to Based upon these preliminary finding~, further define the role of PEP therapy m this pauent population.
' Title.
Title:
THE UTILITY OF THE ROUTINE POSTTHORACENTESIS CHEST RADIOGRAPH. Author(s): D. Gerardi, MD, * P. Scalise, MD, B.
Lahiri, MO, FCCP. University of Connecticut School of Medicine, Farmington, CT, and st. Francis Hospital and Medical Center, Hartford, CT. A post-thoracentesis chest X-ray (CXR) is routinely obtained in most medical centers. To evaluate the utility of this practice, we reviewed the records of all adult medical and surgical patients who had a thoracentesis performed over a one year period in a large community teaching hospital. One-hundred thirty-four procedures were reviewed. Of these, 121 (90%) had post-thoracentesis chest xrays. None of the 13 patients without post-procedure CXR's were or became symptomatic of pneumothorax (PTX). Ten patients (7.5% of total) had PTX on CXR; 3 were asymptomatic and 7 were symptomatic of PTX. New-onset or increased dyspnea was present in all symptomatic patients. None of the asymptomatic patients required intervention, but 4 of the symptomatic patients required tube thoracostomy. These results question the necessity of obtaining routine postthoracentesis CXR's in hospitalized patients who remain free of PTX symptoms.
LOW YIELD OF ·CONPUTED TOMOGRAPHY SCAN· IN
Title: ROUTINE. evALUATION OF PLEURAL EFFUS IONS Author(s}: B. Pat janasoontorrrs, M.D., M. Zeitouni, M.D.
VA Medical Center, Cleveland, Ohio
We did a retrospective chart review to evaluate the etility of adding CT scan in the work-up of pleural effusions. Out of 95 charts reviewed 46 had CT solely for evaluation of pleural effusion. A Pulmonary consultation was obtained in 14 prior to cr and recorrmended it in 10. cr was considered helpful if it added new information directing diagnostic workup to a specific etiology. cr was helpful in one patient with loculated effusion with negative bronchoscopy by finding hilar and subcarinal adenopathy not seen on CXR. Thoracotomy revealed metastatic adena Ca of unknown primary. In 45 patients (10 with transudative effusion, 3 malignant, 8paramalignant, 5 empyema, 5 parapneumoni.c , 2 trapped lung, 1 tuberculous, 1 su1:xliaphragmatic procedure related, and 10 undiagnosed effusions) CT added no additional helpful information. We conclude used in the rarely adds work-up and
that CT scan of the chest is commonly evaluation of pleural effusions and information to the standard diagnostic its routine use should be discouraged.
CHEST I 106 I 2 I AUGUST, 1994 / Supplement
838
Monday, October 31, 1994 Pulmonary Diagnostic and Monitoring Techniques" continued THE "DEEP VALLECULA" SIGN; A FINDING WHICH IMPROVES THE ACCURACY OF NECK XRAYS IN THE Author(s): DIAGNOSIS OF ADULT EPIGLOTTITIS. Yadranko Ducic', Keith Neufeld', Paul C Hebert', Ian Hammond' Andre Lamothe I and Adele Quarringtorr', Depts of Otolaryngology', Radiology' and Medicine' University of Ottawa, Ottawa. Canada Soft tissue Xrays of the'''JCk are frequently employed as a screening test for epiglottitis. Using accepted criteria, the interpretation of small 'numbers of films is reported to yield a false negative rate of 0% to 45% and a false positive rate 30%. This study describes and prospectively evaluates a new sign which increases the diagnostic accuracy of neck Xrays in the screening for epiglottitis. A review of 5 soft tissue Xrays of the neck from confirmed cases revealed the absence of a thin deep strip of air defining the anterior surface of the epiglottis in all cases which we termed the "deep vallecula" sign. 26 patients who had soft tissue Xrays and epiglottitis confirmed by direct visualization were subsequently identified. An additional 26 normal neck Xrays from patients suspected of having epiglottitis or foreign bodies were also identified. All participants attended a standard 10 minute tutorial describing the "deep vallecula" sign. The 52 Xrays were then arranged randomly and read by medical students (n=2), emergentologists (n=2), radiologists (n=2) and otolaryngology residents (n=2). Both participants and researchers were unaware of previous reports and test results. The overall accuracy of official Xray reports from staff radiologists was 75% prior to the description of this sign. Participants correctly classified Xrays with a 95% accuracy rate following the tutorial. Sensitivity was 96% and specificity 94% overall. The diagnostic accuracy of all participating groups was comparable. In conclusion, the use of the deep vallecula sign alone increases the diagnostic accuracy of soft tissue Xrays of the neck in the diagnosis of adult epiglottitis. Therefore, neck Xrays may be a useful screening test. In addition, the sign is easily taught and just as easily applied.
Title.
.
ntle: Author(s):
CHEST X-RAY INTERPRETATION BY MEDICAL HOUSESTAFF DO THEY REQUIRE MORE TRAINING??
*Ashok C. Solsi MD, Ahmar A. Butt MD, Madhu R. Dukkipati, MD, Eliot J. Lazar MD, FCCP. The Brooklyn Hospital Center, Brooklyn, New York.
Medical housestaff are often expected to interpret admission chest x-rays and initial treatment is frequently based on these findings. To determine the accuracy of these housestaff interpretations (HI's) we did a retrospective analysis of 102 randomly selected chest x-rays of patients admitted to a medical service over six months. Housestaffinterpretations were recorded, then compared against the official radiology report. Housestaff included PGY -I, PGY-2, and PGY-3. We selected the following parameters: Infiltrate (I), cardiac size (CS), "pulmonary congestion (PC), pleural effusion (PEF), mediastinallhilar masses (M), parenchymal mass (PM), atelectasis (AT) and overall error rate for analysis. Both false negatives and false positives were assessed. In total, housestaff interpretations correlated with the radiologist in 47/102 (46.1 %). In 55/102 (53.9%) there were discrepancies from the official report. In the specific findings evaluated there were a total of 83 errors, 28(1), 20(CS), 9(PC), 9(PEF), 7(M), 3(PM), 7(AT). Interestingly, although the highest absolute error rate was related to infiltrate and cardiac size, 100% of AT were missed by housestaff, 75% of PEF were missed, and 70% of M were missed. When compared by PGY status, there was considerable improvement with advanced levels of training. The error rate was for PGY-1 23/39 (59%), PGY-2 17/32 (53.1 %), PGY-3 13/31 (42%). We suggest from this preliminary study that there may be a significant error rate in housestaff interpretation of admission CXRs and that this error rate improves with advancing PGY status. These findings require confirmation and the impact, if any, on patient care should be determined.
848
Title:
rosr-PRCX:IDJRE CHEST RADIOSRA.f'HS ARE UNNECESSARY IF CENTRAL LINES ARE CHANGED OVER A GUIDE-WIRE Author(s): Rumbak MJ ,FCCP*, Alfonso D, Modh A, et al Veneor & USF College of Medicine, Tpa, FL Introduction: Replacing central venous catheters (CVC) over a guide-wire is used to reduce CVC related infections. Many hospitals require routine chest x-rays post procedure to rule out pneumothoraces (PT) and malpositions (MP). Recent literature suggests these are unnecessary. Methods: During 1993, the prevalence of PT and M? were retrospectively reviewed in 553 consecutive long t.e rm , acute care ventilated patients. The catheter was marked, pulled out until only 18cm of catheter was left and cut off. The newgui"ie -wi r e was inserted, the rest of the catheter removed ana a new one inserted to t~e sase ?osition as the old one. MP was &i~~~o~e~ if t~e c~t~eter was in the jugular vein, against and yergendicular to the wall of the superior vena cava, or in the right atrium. Results: There were 266 c~theters placed in the right subclavian vein (RSV), 284 in the left subclavian vein (LSV), and 3 in the left internal jugular vein. There was 1 PT (0.18%) from an RSV catheter and 3 MP(O.54%) from the RSV(2) and LSV(l) Concl usions : When a standard technique is used the prevalence of PT and MP is 0.18% and 0.54% respectively. The PT was thought to have occurred before the guide-wire exchange. The prevalence of PT or MP is so low that post x-rays are not needed. This would have saved the patients $82,950.
Title: Author(s):
RELATIONSHIP BETWEEN PLASMAPHERESIS AND MEASUREMENTS OF RESPIRATORY MUSCLE STRENGTH IN THE GUILLAIN-BARRE SYNDROME
D. Gerber DO,FCCP, R. Solanki MD·, J. Kass MD,FCCP, UMDNJ/Robert Wood Johnson Medical School, Camden NJ Plasmapheresis has become a mainstay of therapy for the Guillain-Barre Syndrome (GBS), and is felt to shorten the course of disease in treated patients. We chose to prospectively assess the impact of pheresis on measurements of respiratory muscle strength when measured in relation to specific pheresis sessions. A total of 14 patients with GBS have been studied by us to date. Patients have baseline (pretreatment) measurements of Vital Capacity (VC) and Negative Inspiratory Force (NIF), and repeat measurements at 6, 12, and 24 hours after each plasmapheresis session. The plasmapheresis protocol at our institution has the first two sessions performed 24 hours apart, with subsequent sessions usually every 48 hours thereafter. The majority of patients have a total of 5 to 7 sessions. No significant difference in measurements of respiratory muscle strength could be detected either in the 24 hours immediately following individual sessions of plasmapheresis, or between consecutive sessions. However, significant improvements could be seen when baseline VC (measured before the first plasmapheresis session) was compared to VC prior to treatment session number 4 (48 hours after session number 3, mean 5.3 days after baseline measurements) and prior to session number 5 (48 hours after session number 4). All 14 patients had data comparing baseline VC with VC before treatment number 4, with an increase in mean VC from 1.67L to 1.96L (p < 0.05). Thirteen patients had data comparing baseline VC with VC 'pretreatment number 5, with a change in mean VC from 1.65L to 1.97L (p < 0.05). Insufficient data was available to assess the response to 5 or more sessions. 11 patients were not intubated at enrollment. None of the 7 with improved VC by day 5 required intubation, in contrast to 2 of 4 non-responders who did. These results indicate that plasmapheresis may have a cumulative beneficial effect on respiratory muscle strength by the start of the fourth treatment. Conversely, failure to respond to plasmapheresis by day 5 may be associated with an increased risk of the need for intubation.
Abstracts, 60th Annual International Scientific Assembly
Monday, October 31, 1994
Title:
LUNG AUSCULTATION AMONG PHYSICIANS TRAINING: A LOST.ART? Author(s): S.Mangione, MD*, and S.B. Fiel, MD, FCCP Medical College of Pennsylvania, Philadelphia, PA
IN
We live in times of sophisticated diagnostic technology and declining interest in bedside clinical skills. To evaluate the impact that modem technology and current training practices may have had upon physical diagnosis, we tested the pulmonary auscultatory skills of 124 internal medicine residents, 11 pulmonary fellows and 63 medical students of six University-affiliated programs of the Philadelphia and Pittsburgh area. Most of these physicians had not been exposed to any structured teaching of pulmonary auscultation during their internal medicine or pulmonary training. Participants were asked to listen by stethophones to a tape containing 10 respiratory events, directly recorded from patients and selected out of a pool of 200 sounds. Participants were allowed to listen to each event as long as needed and answered by filling a multiple choice questionnaire. The trainees' accuracy ranged between 0-100% for pulmonary fellows (median = 54.5) and 13.7-82.3% for medical residents (median = 51.6). When compared to medical residents, pulmonary fellows showed a higher identification rate only for the pleural friction rub (72.7% vs. 41.9%, P=O.05) and the end-inspiratory crackles of interstitial fibrosis (45.5% vs. 13.7%, P=0.02). Medical residents did not significantly improve with year of training and were never signifcantly better than fourth year medical students. These data confirm recent studies indicating that house officers are prone to making critical errors when doing physical examination. They also suggest that the major burden of preparing future physicians in this time-honored art may now rest mainly on medical schools, and that the deficiencies noted in the performance of physical examinations by students receiving their medical degree (Sox, He et al. J.Med.Educ. 1984; 59 (II pt 2):139-147) may not be corrected during SUbsequent training.
PITFALLS IN THE VALUE OF END TIDAL CO 2 DETECTION Author(s): Joseph Mathew, M.D.,· Yizhak Y. Kupfer, M.D., Sidney Tessler, M.D.,FCCP. Division of Pulmonary & Critical Care Medicine, Maimonides Medical Center, Brooklyn,
TItle:
N.Y.
Endotracheal intubation is performed frequently by many individuals with differing medical backgrounds and levels of experience. One of the mostsserious complications associated with the procedure is the intubation of the esophagus. Disposable end tidal carbon dioxide (EtC0 2 ) detectors have been used widely to confirm tracheal intubation, and have been reported to be highly accurate. We observed two cases in which patients undergoing cardiopulmonary resuscitation (CPR) were intubated and disposable EtC0 2 detectors failed to detect CO 2 , The endotracheal tubes were then removed and the patients were reintubated with the same results. In one case, tube position was eventually confirmed by fiberoptic bronchoscopy. In the second case, the patient underwent an emergency tracheostomy but finally required intubation and the tube was directly visualized via the tracheostomy tract. At no time was CO 2 detected with the EtC0 2 detector. In patients with cardiac arrest undergoing CPR, absence of color change on the disposable EtC0 2 detector may be of limited value in indicating esophageal intubation. In these situations inconsistency of cellular metabolism and abnormal circulation cause inadequate CO 2 production and delivery. Hence, if there is absence of color change on EtC02 detector, the ET tube position should be confirmed by other means such as flexible fiberoptic bronchoscopy.
Pulmonary Disease in HIV Infection 10:30 AM -11 :20 AM TITLE: AUTHOR{S):
COMPARISON BETWEEN THE MEASUREMENT OF NASAL MUCOCILIARY CLEARENCE (NMC) BY SAC CHARINE TEST (8T) AND RADIOISOTOPIC METHOD.
Rizzo, JA*; Pitanga, NM; Campelo, R; Souza, H; Marchetti, F. Universidade Federal de Pernambuco - Brazil. Measurement of NMC can be done by saccharine test and radioisotopic method. The objective of this study was to evaluate the correlation between these two methods executed at the same time.
Methods: 2,5 mCi of colloidal Tc 99m AND 30 mg of saccharine were diluted in 0,5 ml of phisiologic solution and 0,1 ml placed on the floor of nasal cavity of 9 normal individuals, in two different days (18 measurements ). In seated position, the time to feel the sweet taste was measured in minutes and the progression of the radioisotope followed by gamma camera, in mm / rnin., for 15 min .. saccharine min.
Results: The mean time of ST was 9,37 ± 4,3 min. and the mean velocity of radioisotope was 9,3 ± 2,4 mm / min. with an r = - 0,8, (p < 0,05 ).
20 15
10 5
\
~~.,
.. •"-:,
-."',
5
. • r =·0,8
10 15 20
Tc 99m
- mm I min.
Conclusion: NMC measured by these two methods showed good correlation and the 8T, for its simplicity, can be reliably emploied to measure NMC.
TItle:
CHYLOTHORAX IN THE HIV POSITIVE PATI~NT
.Soni P. MD*, Fontana L. MO,FCCP, Smith L. MO,
AUthor(s)"Talavera W. MD,FCCP
Cabrini Medicai Center, New York Medicai Coiiege, NY,NY We conducted a retrospective study from July 1990 through December 1993 analyzing pleural effusions in HIV positive (HIV+) patients at our institution. We identified 200 HIV+ patients with pleural effusions, all of whom had diagnostic thoracenteses. Nine (4.5%) patients were diagnosed as having a chylothorax (CTX), which was defined as a triglyceride level above 110 mg/dl and pleural fluid cytology with lymphocytic predominance. Initial pleural fluid appearance was: milky (4), serosanguinous (2), bright yellow (1) and cloudy red (2). The mean triglyceride level was 440.67 (125-984), the mean cholesterol level was 46.45 (1Q-91) and lymphocyte differential was 71% (95-44). Probable causative conditions in our 9· patients with CTX were 4 patients with disseminated Kaposi sarcoma (KS) and bronchoscopy proven lung involvement, 2 patient with culture proven mycobacterial disease, 2 patients with iatrogenic CTX (one secondary to chest tube placement, another from central line placement) and 1 patient with probable malignancy. Patients were treated conservatively -with a low fat diet, medium chain triglycerides, TPN, chest tube drainage and/or radiotherapy. One patient responded to repositioning of the chest tube and one responded to treatment with antituberculous medication. Five of the nine patients expired despite treatment. CTX is an infrequent occurrence but when present usually carries significant morbidity in any patient population. Our data show KS is a common cause of chylothorax in HIV+ patients and suspicion should be high for early diagnosis and more aggressive treatment. We suggest that in HIV+ patients, a triglyceride analysis of pleural fluid should be considered in the initial evaluation of exudative pleural effusion, regardless of the initial gross appearance.
CHEST / 106 / 2 / AUGUST, 1994 / Supplement
8SS
Author(s)c Licskat, N Zamel, J Maurer, University of Toronto, Toronto, Ontario To evaluate the effect of lung elasticity on PFT posttransplant, we analyzed 69 static compliance curves of 44 patients obtained between 3 & 18 months post double lung transplant (OL1). Pressure-volume points were fitted to the single exponential V=ABe-KP using the Marquardt-Levenberg algorithm (V=volume, P=pressure, A,B,K=constants). Mean R2=0.90. Mean maximum inspiratory pressure was 91 ±25. 7% predicted. TLC & FAC were not different from the donor or recipient predicted. The shape constant of the curve,K, is a volume independent measure of the retractive force of the lung between 50-100% TLC. Measured K approximated the donor predicted K and was lower than the recipient predicted. FEV1/FVCwas greater than recipient predicted and tended toward being higher than donor predicted. We conclude that DLTs receive donor lungs with higher than predicted elasticity. Despite this FAC is 94% of recipient predicted suggesting a coincident increase in chest wall recoil. The tendency toward FEV1/FVC > predicted donor flows suggests undersizing as an explanation for increased chest wall recoil. Cohort P < Donor Pred. Recip. Pred. P <
K
TLC(L) TLC(L) FRC(l)
.13837 ±.0114
75.9 ±2.8 5.59 ±.89 3.08 ±.53
.05
.003 ..91 .29
.12246 ±.0498 83.0 ±14.1 5.56 ±1.26 3.2~
±.72
NS
.08 N8
NS
.12716 ±.012
78.8 ±3.9 5.95 ±1.44 3.15 ±.74
POSITIVE EXPIRATORY PRESSURE THERAPY IN THE POST-OP CARE OF THE LUNG TRANSPLANT PATIENT . Jeffrey Tarnow, RRT*, & Michae~ Manlmeister, M~, RRT Author(s). Medical Center at the U. of California, San FranCISCO INTRODUCTION Following lung transplant, respiratory care is normally provided to maintain t~e l!se of lung expansion and facilitate secretion clearance, ~ncluding postural drainage and percussion (PD&P). We descnbe the application of an alternative bronchial hygiene technique, Positive Expiratory Pressure (PEP) therapy, in a series of 8 lung transplant patients. PEP is performed with the patient sitting up in bed. They inspire a slow maximum breath, perform a 3 second breath hold, then actively exhale through a fixed orifice A ser~es of resistor, creating an expiratory pressure between lO-~OcmH2~. 20-30 PEP breaths are performed, followed by coughmg to raise secreuons, METHODS Eight patients underwent single lung transplantation~ mean age 46 q4-5~). Diagnoses included COPD (5), pulmonary hypertension, alpha I anutrypsm deficiency, and pulmonary fibrosis. Following extubation patients received PEP therapy Q4 hours w/a & pm, along with Incentive Spirometry, plus aerosol bronchodilators pm. On ICU discharge, PEP was provided QID for a minimum of 3 days. then patients were evaluated for self-administration. RESULTS All 8 patients received PEP therapy Q4hours w/a in ICU. Post-K'U discharge, patients received therapist-administered PEP QID for an ave~age of 3.8 days, followed by transition to self-performed PE~. No 'pauent required additional therapy such as PD&P or IPPB dunng theI~ postoperative recovery, and no patient required return to ICU for resplfat~ry failure. No patient required bronchoscopy intervention for secreuon retention or atelectasis, and no patient had any complications from PEP therapy. Mean ICU stay was 5.1 days, mean hospital stay was 16.6 days. DISCUSSION PEP therapy represents a safe, effective alternative to PD&P in this patient population. Advantages include shorter treatment time c~mpare~ to PD&P and avoidance of adverse cardiopulmonary effects associated WIth PD&P. PEP can produce significant cost savings, since it can be self-administered. fw:ther studies are recommended to Based upon these preliminary finding~, further define the role of PEP therapy m this pauent population.
' Title.
Title:
THE UTILITY OF THE ROUTINE POSTTHORACENTESIS CHEST RADIOGRAPH. Author(s): D. Gerardi, MD, * P. Scalise, MD, B.
Lahiri, MO, FCCP. University of Connecticut School of Medicine, Farmington, CT, and st. Francis Hospital and Medical Center, Hartford, CT. A post-thoracentesis chest X-ray (CXR) is routinely obtained in most medical centers. To evaluate the utility of this practice, we reviewed the records of all adult medical and surgical patients who had a thoracentesis performed over a one year period in a large community teaching hospital. One-hundred thirty-four procedures were reviewed. Of these, 121 (90%) had post-thoracentesis chest xrays. None of the 13 patients without post-procedure CXR's were or became symptomatic of pneumothorax (PTX). Ten patients (7.5% of total) had PTX on CXR; 3 were asymptomatic and 7 were symptomatic of PTX. New-onset or increased dyspnea was present in all symptomatic patients. None of the asymptomatic patients required intervention, but 4 of the symptomatic patients required tube thoracostomy. These results question the necessity of obtaining routine postthoracentesis CXR's in hospitalized patients who remain free of PTX symptoms.
LOW YIELD OF ·CONPUTED TOMOGRAPHY SCAN· IN
Title: ROUTINE. evALUATION OF PLEURAL EFFUS IONS Author(s}: B. Pat janasoontorrrs, M.D., M. Zeitouni, M.D.
VA Medical Center, Cleveland, Ohio
We did a retrospective chart review to evaluate the etility of adding CT scan in the work-up of pleural effusions. Out of 95 charts reviewed 46 had CT solely for evaluation of pleural effusion. A Pulmonary consultation was obtained in 14 prior to cr and recorrmended it in 10. cr was considered helpful if it added new information directing diagnostic workup to a specific etiology. cr was helpful in one patient with loculated effusion with negative bronchoscopy by finding hilar and subcarinal adenopathy not seen on CXR. Thoracotomy revealed metastatic adena Ca of unknown primary. In 45 patients (10 with transudative effusion, 3 malignant, 8paramalignant, 5 empyema, 5 parapneumoni.c , 2 trapped lung, 1 tuberculous, 1 su1:xliaphragmatic procedure related, and 10 undiagnosed effusions) CT added no additional helpful information. We conclude used in the rarely adds work-up and
that CT scan of the chest is commonly evaluation of pleural effusions and information to the standard diagnostic its routine use should be discouraged.
CHEST I 106 I 2 I AUGUST, 1994 / Supplement
838
Monday, October 31, 1994 Pulmonary Diagnostic and Monitoring Techniques" continued THE "DEEP VALLECULA" SIGN; A FINDING WHICH IMPROVES THE ACCURACY OF NECK XRAYS IN THE Author(s): DIAGNOSIS OF ADULT EPIGLOTTITIS. Yadranko Ducic', Keith Neufeld', Paul C Hebert', Ian Hammond' Andre Lamothe I and Adele Quarringtorr', Depts of Otolaryngology', Radiology' and Medicine' University of Ottawa, Ottawa. Canada Soft tissue Xrays of the'''JCk are frequently employed as a screening test for epiglottitis. Using accepted criteria, the interpretation of small 'numbers of films is reported to yield a false negative rate of 0% to 45% and a false positive rate 30%. This study describes and prospectively evaluates a new sign which increases the diagnostic accuracy of neck Xrays in the screening for epiglottitis. A review of 5 soft tissue Xrays of the neck from confirmed cases revealed the absence of a thin deep strip of air defining the anterior surface of the epiglottis in all cases which we termed the "deep vallecula" sign. 26 patients who had soft tissue Xrays and epiglottitis confirmed by direct visualization were subsequently identified. An additional 26 normal neck Xrays from patients suspected of having epiglottitis or foreign bodies were also identified. All participants attended a standard 10 minute tutorial describing the "deep vallecula" sign. The 52 Xrays were then arranged randomly and read by medical students (n=2), emergentologists (n=2), radiologists (n=2) and otolaryngology residents (n=2). Both participants and researchers were unaware of previous reports and test results. The overall accuracy of official Xray reports from staff radiologists was 75% prior to the description of this sign. Participants correctly classified Xrays with a 95% accuracy rate following the tutorial. Sensitivity was 96% and specificity 94% overall. The diagnostic accuracy of all participating groups was comparable. In conclusion, the use of the deep vallecula sign alone increases the diagnostic accuracy of soft tissue Xrays of the neck in the diagnosis of adult epiglottitis. Therefore, neck Xrays may be a useful screening test. In addition, the sign is easily taught and just as easily applied.
Title.
.
ntle: Author(s):
CHEST X-RAY INTERPRETATION BY MEDICAL HOUSESTAFF DO THEY REQUIRE MORE TRAINING??
*Ashok C. Solsi MD, Ahmar A. Butt MD, Madhu R. Dukkipati, MD, Eliot J. Lazar MD, FCCP. The Brooklyn Hospital Center, Brooklyn, New York.
Medical housestaff are often expected to interpret admission chest x-rays and initial treatment is frequently based on these findings. To determine the accuracy of these housestaff interpretations (HI's) we did a retrospective analysis of 102 randomly selected chest x-rays of patients admitted to a medical service over six months. Housestaffinterpretations were recorded, then compared against the official radiology report. Housestaff included PGY -I, PGY-2, and PGY-3. We selected the following parameters: Infiltrate (I), cardiac size (CS), "pulmonary congestion (PC), pleural effusion (PEF), mediastinallhilar masses (M), parenchymal mass (PM), atelectasis (AT) and overall error rate for analysis. Both false negatives and false positives were assessed. In total, housestaff interpretations correlated with the radiologist in 47/102 (46.1 %). In 55/102 (53.9%) there were discrepancies from the official report. In the specific findings evaluated there were a total of 83 errors, 28(1), 20(CS), 9(PC), 9(PEF), 7(M), 3(PM), 7(AT). Interestingly, although the highest absolute error rate was related to infiltrate and cardiac size, 100% of AT were missed by housestaff, 75% of PEF were missed, and 70% of M were missed. When compared by PGY status, there was considerable improvement with advanced levels of training. The error rate was for PGY-1 23/39 (59%), PGY-2 17/32 (53.1 %), PGY-3 13/31 (42%). We suggest from this preliminary study that there may be a significant error rate in housestaff interpretation of admission CXRs and that this error rate improves with advancing PGY status. These findings require confirmation and the impact, if any, on patient care should be determined.
848
Title:
rosr-PRCX:IDJRE CHEST RADIOSRA.f'HS ARE UNNECESSARY IF CENTRAL LINES ARE CHANGED OVER A GUIDE-WIRE Author(s): Rumbak MJ ,FCCP*, Alfonso D, Modh A, et al Veneor & USF College of Medicine, Tpa, FL Introduction: Replacing central venous catheters (CVC) over a guide-wire is used to reduce CVC related infections. Many hospitals require routine chest x-rays post procedure to rule out pneumothoraces (PT) and malpositions (MP). Recent literature suggests these are unnecessary. Methods: During 1993, the prevalence of PT and M? were retrospectively reviewed in 553 consecutive long t.e rm , acute care ventilated patients. The catheter was marked, pulled out until only 18cm of catheter was left and cut off. The newgui"ie -wi r e was inserted, the rest of the catheter removed ana a new one inserted to t~e sase ?osition as the old one. MP was &i~~~o~e~ if t~e c~t~eter was in the jugular vein, against and yergendicular to the wall of the superior vena cava, or in the right atrium. Results: There were 266 c~theters placed in the right subclavian vein (RSV), 284 in the left subclavian vein (LSV), and 3 in the left internal jugular vein. There was 1 PT (0.18%) from an RSV catheter and 3 MP(O.54%) from the RSV(2) and LSV(l) Concl usions : When a standard technique is used the prevalence of PT and MP is 0.18% and 0.54% respectively. The PT was thought to have occurred before the guide-wire exchange. The prevalence of PT or MP is so low that post x-rays are not needed. This would have saved the patients $82,950.
Title: Author(s):
RELATIONSHIP BETWEEN PLASMAPHERESIS AND MEASUREMENTS OF RESPIRATORY MUSCLE STRENGTH IN THE GUILLAIN-BARRE SYNDROME
D. Gerber DO,FCCP, R. Solanki MD·, J. Kass MD,FCCP, UMDNJ/Robert Wood Johnson Medical School, Camden NJ Plasmapheresis has become a mainstay of therapy for the Guillain-Barre Syndrome (GBS), and is felt to shorten the course of disease in treated patients. We chose to prospectively assess the impact of pheresis on measurements of respiratory muscle strength when measured in relation to specific pheresis sessions. A total of 14 patients with GBS have been studied by us to date. Patients have baseline (pretreatment) measurements of Vital Capacity (VC) and Negative Inspiratory Force (NIF), and repeat measurements at 6, 12, and 24 hours after each plasmapheresis session. The plasmapheresis protocol at our institution has the first two sessions performed 24 hours apart, with subsequent sessions usually every 48 hours thereafter. The majority of patients have a total of 5 to 7 sessions. No significant difference in measurements of respiratory muscle strength could be detected either in the 24 hours immediately following individual sessions of plasmapheresis, or between consecutive sessions. However, significant improvements could be seen when baseline VC (measured before the first plasmapheresis session) was compared to VC prior to treatment session number 4 (48 hours after session number 3, mean 5.3 days after baseline measurements) and prior to session number 5 (48 hours after session number 4). All 14 patients had data comparing baseline VC with VC before treatment number 4, with an increase in mean VC from 1.67L to 1.96L (p < 0.05). Thirteen patients had data comparing baseline VC with VC 'pretreatment number 5, with a change in mean VC from 1.65L to 1.97L (p < 0.05). Insufficient data was available to assess the response to 5 or more sessions. 11 patients were not intubated at enrollment. None of the 7 with improved VC by day 5 required intubation, in contrast to 2 of 4 non-responders who did. These results indicate that plasmapheresis may have a cumulative beneficial effect on respiratory muscle strength by the start of the fourth treatment. Conversely, failure to respond to plasmapheresis by day 5 may be associated with an increased risk of the need for intubation.
Abstracts, 60th Annual International Scientific Assembly
Monday, October 31, 1994
Title:
LUNG AUSCULTATION AMONG PHYSICIANS TRAINING: A LOST.ART? Author(s): S.Mangione, MD*, and S.B. Fiel, MD, FCCP Medical College of Pennsylvania, Philadelphia, PA
IN
We live in times of sophisticated diagnostic technology and declining interest in bedside clinical skills. To evaluate the impact that modem technology and current training practices may have had upon physical diagnosis, we tested the pulmonary auscultatory skills of 124 internal medicine residents, 11 pulmonary fellows and 63 medical students of six University-affiliated programs of the Philadelphia and Pittsburgh area. Most of these physicians had not been exposed to any structured teaching of pulmonary auscultation during their internal medicine or pulmonary training. Participants were asked to listen by stethophones to a tape containing 10 respiratory events, directly recorded from patients and selected out of a pool of 200 sounds. Participants were allowed to listen to each event as long as needed and answered by filling a multiple choice questionnaire. The trainees' accuracy ranged between 0-100% for pulmonary fellows (median = 54.5) and 13.7-82.3% for medical residents (median = 51.6). When compared to medical residents, pulmonary fellows showed a higher identification rate only for the pleural friction rub (72.7% vs. 41.9%, P=O.05) and the end-inspiratory crackles of interstitial fibrosis (45.5% vs. 13.7%, P=0.02). Medical residents did not significantly improve with year of training and were never signifcantly better than fourth year medical students. These data confirm recent studies indicating that house officers are prone to making critical errors when doing physical examination. They also suggest that the major burden of preparing future physicians in this time-honored art may now rest mainly on medical schools, and that the deficiencies noted in the performance of physical examinations by students receiving their medical degree (Sox, He et al. J.Med.Educ. 1984; 59 (II pt 2):139-147) may not be corrected during SUbsequent training.
PITFALLS IN THE VALUE OF END TIDAL CO 2 DETECTION Author(s): Joseph Mathew, M.D.,· Yizhak Y. Kupfer, M.D., Sidney Tessler, M.D.,FCCP. Division of Pulmonary & Critical Care Medicine, Maimonides Medical Center, Brooklyn,
TItle:
N.Y.
Endotracheal intubation is performed frequently by many individuals with differing medical backgrounds and levels of experience. One of the mostsserious complications associated with the procedure is the intubation of the esophagus. Disposable end tidal carbon dioxide (EtC0 2 ) detectors have been used widely to confirm tracheal intubation, and have been reported to be highly accurate. We observed two cases in which patients undergoing cardiopulmonary resuscitation (CPR) were intubated and disposable EtC0 2 detectors failed to detect CO 2 , The endotracheal tubes were then removed and the patients were reintubated with the same results. In one case, tube position was eventually confirmed by fiberoptic bronchoscopy. In the second case, the patient underwent an emergency tracheostomy but finally required intubation and the tube was directly visualized via the tracheostomy tract. At no time was CO 2 detected with the EtC0 2 detector. In patients with cardiac arrest undergoing CPR, absence of color change on the disposable EtC0 2 detector may be of limited value in indicating esophageal intubation. In these situations inconsistency of cellular metabolism and abnormal circulation cause inadequate CO 2 production and delivery. Hence, if there is absence of color change on EtC02 detector, the ET tube position should be confirmed by other means such as flexible fiberoptic bronchoscopy.
Pulmonary Disease in HIV Infection 10:30 AM -11 :20 AM TITLE: AUTHOR{S):
COMPARISON BETWEEN THE MEASUREMENT OF NASAL MUCOCILIARY CLEARENCE (NMC) BY SAC CHARINE TEST (8T) AND RADIOISOTOPIC METHOD.
Rizzo, JA*; Pitanga, NM; Campelo, R; Souza, H; Marchetti, F. Universidade Federal de Pernambuco - Brazil. Measurement of NMC can be done by saccharine test and radioisotopic method. The objective of this study was to evaluate the correlation between these two methods executed at the same time.
Methods: 2,5 mCi of colloidal Tc 99m AND 30 mg of saccharine were diluted in 0,5 ml of phisiologic solution and 0,1 ml placed on the floor of nasal cavity of 9 normal individuals, in two different days (18 measurements ). In seated position, the time to feel the sweet taste was measured in minutes and the progression of the radioisotope followed by gamma camera, in mm / rnin., for 15 min .. saccharine min.
Results: The mean time of ST was 9,37 ± 4,3 min. and the mean velocity of radioisotope was 9,3 ± 2,4 mm / min. with an r = - 0,8, (p < 0,05 ).
20 15
10 5
\
~~.,
.. •"-:,
-."',
5
. • r =·0,8
10 15 20
Tc 99m
- mm I min.
Conclusion: NMC measured by these two methods showed good correlation and the 8T, for its simplicity, can be reliably emploied to measure NMC.
TItle:
CHYLOTHORAX IN THE HIV POSITIVE PATI~NT
.Soni P. MD*, Fontana L. MO,FCCP, Smith L. MO,
AUthor(s)"Talavera W. MD,FCCP
Cabrini Medicai Center, New York Medicai Coiiege, NY,NY We conducted a retrospective study from July 1990 through December 1993 analyzing pleural effusions in HIV positive (HIV+) patients at our institution. We identified 200 HIV+ patients with pleural effusions, all of whom had diagnostic thoracenteses. Nine (4.5%) patients were diagnosed as having a chylothorax (CTX), which was defined as a triglyceride level above 110 mg/dl and pleural fluid cytology with lymphocytic predominance. Initial pleural fluid appearance was: milky (4), serosanguinous (2), bright yellow (1) and cloudy red (2). The mean triglyceride level was 440.67 (125-984), the mean cholesterol level was 46.45 (1Q-91) and lymphocyte differential was 71% (95-44). Probable causative conditions in our 9· patients with CTX were 4 patients with disseminated Kaposi sarcoma (KS) and bronchoscopy proven lung involvement, 2 patient with culture proven mycobacterial disease, 2 patients with iatrogenic CTX (one secondary to chest tube placement, another from central line placement) and 1 patient with probable malignancy. Patients were treated conservatively -with a low fat diet, medium chain triglycerides, TPN, chest tube drainage and/or radiotherapy. One patient responded to repositioning of the chest tube and one responded to treatment with antituberculous medication. Five of the nine patients expired despite treatment. CTX is an infrequent occurrence but when present usually carries significant morbidity in any patient population. Our data show KS is a common cause of chylothorax in HIV+ patients and suspicion should be high for early diagnosis and more aggressive treatment. We suggest that in HIV+ patients, a triglyceride analysis of pleural fluid should be considered in the initial evaluation of exudative pleural effusion, regardless of the initial gross appearance.
CHEST / 106 / 2 / AUGUST, 1994 / Supplement
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