Download Gravity-Dependent Lung Infiltrates

The only difference
between
our cases and those
of
et al is the morphology
of the subpleural
inflammatory
infiltrate,
which was bandlike
in the former
and focal in the latter.
We always found small blood vessels in the region ofthe subpleural
inflammatory
infiltrate,
and sometimes
noted perivascular
inflammatory
infiltrate,
even focal inflammatory
infiltrate,
similar
to that
in the cases of Buchanan
et al. Therefore,
we consider
that any
morphologic
difference in inflammatory inifitrate
reflects
only the
difference
in inflammatory
stage.
The findings of Buchanan
et al
support
our idea that the presence of subpleural mononuclear cell
infiltration
with minimal pleural
inflammation
suggests
the nontuberculous
nature ofthe pleuritis. A prospective study is now under
way to evaluate
more
objectively
the significance of subpleural
inflammatory
infiltrate.
our
paper.
Buchanan
Research
Nobuhiko Nagata,
Diseases ofthe
iristitutefor
Kywshu
University,
Fukuoka,
Reprint
requests:
Chest,
Kyushu
Dr Nagata,
University,
Research
3-1-1
M.D.,
Chest,
Japan
Diseases of the
Higashi-Ku,
FukuOka
Institutefor
Maidashi,
Ficuan
2. Freely
apparent
812, Japan
years
as a
Lung Infiltrates
at different
in
the emphyseniatous
scan.
seen
two cases similar to the one described
by Vandenplas
case report’
in the November
1990 issue of Chest.
Both my patients
had severe
emphysema
and left lower lobe lung
cancer,
no bronchial
obstruction,
and gravity-dependent
left lower
reason
(Figs
had
1 and
standard
one example
to several
who have not seen this phenom-
radiographs.
John
Wtterans
oflipoid
pneumonia,
nor
had
Administration
I any
that this was a consideration.
The common denominator
these cases and the case of Vandenpias
et al is the
severe
emphysema,
which
I believe
is the only requirement
ftw
gravity-dependent
infiltrates.
I have not identified
other cases in 20
V Forrest
Radiology
2).
no history
is
and have shown
institutions
et al in their
lobe infiltrates
These patients
lung
enon. The observation
is much
more apparent on computed
tomographic (CT) scans, and it may be that it occurs occasionally.
However, we rarely obtain CT scans in patients
with
severe
emphysema
and pneumonia,
and the observation is missed
on
lb the Editor:
I have
fluid
tomographic
chest radiologist
colleagues
Gravity-Dependent
flowing
on computed
to think
between
M.D.,
Service,
Medical Center,
LaJolia,
CalIfOrnIa
REFERENCE
1
Vandenpias
0,
Trigaux
JP, Van Beers B, Delaunois
in a patient
with lipoid
Gravity-dependent
infiltrates
Chest 1990; 98:1253-54
L, Sibille
Y.
pneumonia.
u--
lb the Editor:
The cases reported by Dr Forrest demonstrate
that gravitydependent
opacities
can be observed
in a case
of infectious
pneumoniaassociated
with emphysema. This reinkwces
our conclusion that in the presence of alveolar exudate,
emphysema contributes greatly to the mobility ofthe infiltrates.
A striking
feature
in our case was the velocity
of the gravitydependent
changes.
Only a few minutes
elapsed
between
the prone
and
supine
CF
scans.
M.D.,
M.D.,
IMc De15JUflOiS
M.D., EC.C.P,
Bernard %Isn Beers M.D., and
Yves Sibille,
M.D.,
Universitaires
de Mont-Godinrae,
OlIvIer
Vandenplas
Jean-Paul
ClInIqUeS
Trigaux,
Yvoir,
Percutaneous
1.
emphysematous
lkstemanterior
left lower
radiograph
lobe.
shows
a fluid
flacheostomy
7b the Editor:
a:-.
FIGURE
Bejgium
level
in
an
The
by Dr Douglas
editorial
November
1990
issue
J. Mathisen,’
which appeared in the
calls for some comment.
Dr
of Chest,
1178
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21635/ on 06/18/2017
Communications
to the EdItor
a general
thoracic
surgeon
(as I have been
for some
greatly disturbed
about nonsurgeons
doing percutaneous
tracheostomies-and
not doing them in the operating
room! And
doing them in the intensive care unit, at the bedside-and
with the
patient under local anesthesia!
Hejustifiably
points out that ‘new techniques
must bejudged
on
merit by their safety, ease of performance,
cost effectiveness,
and
stand
the test of time . . . “ We also agree with his statement
that
“a meticulous
tracheostomy
performed
under optimal conditions
and carefully attended to postoperatively
should be associated
with
few complications.”
Agreed!
But the same is true of a properly
performed
percutaneous
dilatational
tracheostomy
done with the
patient
under local anesthesia
in the intensive
care unit. Beports
supporting
this opinion’
have appeared.
Dr Mathisen
is also worried, justifiably,
about complications
in
the long run. It takes time to collect enough cases with long-term
follow-up
data to present
an adequate
number. The senior author
of this letter
(PC.) reported
the first percutaneous
dilatational
tracheostomies
in 1985 in Chest,
but my associate
and I have
waited until now to collect
enough cases with long-term follow-up.
Wti reported
on 165 patients
in a paper
delivered
in part in Toronto
at the 56th Annual
Scientific
Assembly
of the American
College
of
Chest Physiciansl;
the full paper
will be submitted
for publication.
Our long-term
clinical
follow-up
on decannulated
patients
shows
no evidence ofany complications.
There are now modern
subspecialists,
such as critical
care
specialists,
intensivists,
pulmonologists,
interventional
radiologists,
and invasive
cardiologists,
who do many percutaneous
and endoscopic procedures.
They implant permanent
cardiac pacemakers,
drain
abscesses
percutaneously,
do percutaneous
angioplasties,
endoscopically
remove polyps ofthe colon, and perform
many other
procedures
that surgeons
did In the past by open operations.
Thirty
years
ago,
the senior author of this letter had to open the
chest wide in order to put his hands in the pleural
cavity
and then
had to place
his finger in the left atrium
to open a stenotic
mitral
valve.
Today,
when
indicated,
a balloon is inserted
percutaneously
through
the venous system and then through the atrial septum
to
dilate the stenotic
valve. This is done by a nonsurgical
specialist!
The editorial writer displays some undue “turf” arrogance
when
he states that “indications for tracheostomy
may be broadened,
thereby performing
tracheostomy
when not appropriate.
Many
intensive
care units are run by nonsurgical
specialists.
They cannot
be expected
to have the historic perspective
of the results of
emergency
tracheostomy
and what surgical
precautions
are now
Mathisen,
years),
taken
was
to ensure
the fewest
complications
possible”
Since when
does a surgeon decide when a critically
ill medical patient needs an
elective tracheostomy?
Isn’t the pulmonologist
or the intensivist
or
the critical care specialist
who is attending
the patient competent
to decide
when it is time to go from a translaryngeal
tube to
tracheostomy?
These subspecialists
are certainly
as good as, if not
better
than, any surgeon
at making
this particular
decision.
And
they are doing it all the time.
In addition,
these nonsurgical
specialists
will be the judges
as to
whether
their
patients
who undergo
percutaneous
dilatational
tracheostomy
done under local anesthesia
in the intensive care unit
do as well as, or better than, the patients operated on in the surgical
suite.
And if these nonsurgeons
decide
to do the procedure
themselves,
after proper
preparation
and credentialing,
there is
enough
turffor
two (or more) specialties.
Thsquale
Claglia,
Kenneth
M.D.,
F.C.C.R(E.)
D.
Bedside
percutaneous
tracheostomy:
experience
with 55
elective procedures.
Ann Thorac Surg 1988; 46:63-7
3 Paul A, Mardi
D, Chiu
RO, Vestweber
KH,
Mulder
DS.
Percutaneous
endoscopic
tracheostomy.
Ann Thorac Surg 1989;
RM.
47:31415
4 Holtzman
RB. Percutaneous
approach
Cnt Care Med 1989; 17:535
5 Cook
PD, Callanan
VI. Percutaneous
technique
and experience.
Anesth
to tracheostomy
dilatational
Intensive
Care
(letter).
tracheostomy:
1989; 17:456-
57
6 Mardi
D, Paul A, Manolidis
S. Walsh C, Odim JN, Burdon TA,
et al. Endoscopic
guided
percutaneous
tracheostomy:
early
results ofa consecutive trial. J Trauma
1990; 30:433-35
7 Ciaglia R Firsching
R, Syniec
C. Elective
percutaneous
dilatational
tracheostomy:
nary report.
Chest
8 Ciaglia
P, Graniero
a new
simple
bedside
procedure-prelimi-
1985; 87:715-19
K. Percutaneous
dilatational
subcricoid
tmcheostomy.
Presented
at the 56th Annual Scientific Assembly
of
the American
College ofChest
Physicians,
Toronto, Oct 23, 1990
Fiberoptic
Bronchoscopy
without
Premedicatlon
Ib the Editor:
We read
appeared
with
in the
interest
the report by Colt and Morris,’ which
1990 issue of Chest. It was reassuring
premedication,
many elderly patients did not
December
that despite
have a higher complication rate when compared with those who did
not receive any premedications.
However,
we were
surprised
when
the authors
concluded:
“Decreased
facility fees, reduced
medication
and personnel
costs
and decreased
observation
requirements
should lead to decreased
expenditures
withoutcompromisingpatient
care, safety or comfort”
This
retrospective
study
did not evaluate
or report
on patient
comfort.
The level of cooperation
was also not measured.
In a
British
study,t
patient cooperation and comfort were examined
by
asking patients
to answer a few questions
after each bronchoscopic
examination.
While the authors
concluded
that flexible bronchoscopy can be performed
without any preoperative
sedation,
seven of
the 100 patients
received diazepam,
10 mg, intramuscularly
before
the procedure. Thirteen
other patients
described
discomfort
or
displeasure.
Bees et al evaluated
the level ofdiscomfort
during 60
bronchoscopic
procedures
and observed
that 26 of6O (43 percent)
experienced
significant
discomfort
during fiberoptic
bronchoscop
Most patients
found the passage ofthe scope through
the larynx to
be the most difficult part ofthe procedure.
In community
hospitals,
where a significant
percentage
of the
patients
are female, we wonder
how the patient’s comfort
and
cooperation
will not be compromised
without
some preoperative
medications.
How many of these patients
will give a consent for a
second
flexible bronchoscopic examination ifthe flmstwas performed
without appropriate
sedation? Some postoperative
observation
and/
or follow-up
will be required
even if the patient did not receive
preoperative
medication.
Hence,
the cost saving will be minimal.
to note
More important,
we believe
must
along
ation.
be assessed
Cood
patient
that the question
of cost and
safety
patient comfort and optimum
coopercare must include patient comfort as well as
with
cost and safety.
M.D., F.C.C.R,
and
Randy Stubbs
M.D.,
Department
oflnternal
Medicine,
East l#{232}nnesseeState University,
Jay B. Mehta,
and
M.D.,
Graniero,
Utica, New York
frohtuson City, l#{232}nnessee
REFERENCES
1 Mathisen
DJ.
[editoriall.
2 Hazard
Percutaneous
tracheostomy:
a cautionary
PB,
Garrett
HE
Jr, Adams
REFERENCES
note
Chest 1990; 98:1049
1 Colt
JW,
Robbins
E1
Aguillard
cation:
JF. Fiberoptic
a retrospective
study.
HG,
Morris
bronchoscopy
CHEST/100/4/OCTOSER,1991
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21635/ on 06/18/2017
without
premedi-
Chest 1990; 98:1327-30
1179