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A patient with blunt trauma and traumatic bronchial rupture and lung collapse had prominent symptoms of platypnea-orthodeoxia syndrome. These symptoms were relieved by bronchial repair. The syndrome is rarely seen and is usually associated with a patent foramen ovale or atrial septal defect. The syndrome has not been described previously in association with traumatic bronchial rupture., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Three different nonviral vectors and naked DNA were evaluated for in vivo transfer of plasmid DNA to rat lungs through airways in either atelectatic or ventilated lungs., Methods: The F344 rats underwent instillation of 300 microg DNA (pCIluc, luciferase) to the left lung. Naked DNA, linear polyethylenimine, branched polyethylenimine, and lipid GL-67 (in either atelectatic or ventilated lungs) were assessed (n = 5 per group). After 24 hours, left lung PaO2 (mm Hg) and luciferase activity (RLU/mg) were measured. The median (range) was given, and the analysis of variance was applied, followed by the planned comparison on log-transformed data., Results: In atelectatic lungs, lipid GL-67 was best (927 [330 to 4112] RLU/mg; p < 0.001 versus other groups of atelectatic lung; p < 0.001 versus all other groups), but highest luciferase activity in all groups was measured in ventilated lungs using linear polyethylenimine (1,240 [922 to 2519] RLU/mg; p < 0.001 versus other groups of ventilated lung; p < 0.001 versus all other groups). In comparison with naked DNA, all nonviral vector systems significantly impaired PaO2 24 hours after airway transfection (p < 0.001; naked DNA versus all other groups). Regardless of transfection technique, PaO2 was worst in lungs transfected by linear polyethylenimine., Conclusions: Highest transfection was achieved with GL-67 in atelectatic lungs and with linear polyethylenimine in ventilated lungs. All gene delivery systems impaired gas exchange of the transduced lung in comparison with naked DNA.

Hypoxemia during bronchoscopy occurs frequently. It can usually be managed by supplemental oxygen and bronchodilators or, in some cases, occasionally stopping the procedure. Benzocaine spray is commonly used as a topical anesthetic agent during bronchoscopy. However, it has been associated with the development of methemoglobinemia. The following is a case report of hypoxia during bronchoscopy from benzocaine-induced methemoglobinemia and its management.

Total eventration of the hemidiaphragm is a rare condition in adults. We report a 75-year-old woman with large eventration of the right diaphragm who required an emergency plication because of acute progressive respiratory distress. The symptom disappeared immediately after operation. Even in asymptomatic elderly patients with eventration, close follow-up is recommended.

Solitary fibrous tumors of the pleura are rare. Approximately 600 cases have been described in the literature. We report a case of a young man with a giant solitary fibrous tumor of the pleura that filled his entire left hemithorax and anterior mediastinum and extended into the right side of his chest. The diagnostic modalities employed, the operation, and the postoperative management resulting in complete resection of the tumor and full lung reexpansion are described.

Background: This study examined the results of open drainage of massive tuberculous empyema., Methods: During a 7-year period 47 patients with primary mixed chronic tuberculous empyema with near or total lung collapse were treated. The initial procedure was chest tube suction drainage, which permitted evaluation of the pleural cavity and the lung parenchyma despite minimal if any reexpansion of the lung. All patients were treated with antibiotics and multidrug regimens of antituberculosis agents. A pleurocutaneous window was established by removing sections of two ribs one intercostal space above the base of the pleural cavity. Irrigation was performed daily with dilute povidone iodine solution., Results: Twenty-eight patients achieved complete reexpansion of the lung after 4 to 30 months of drainage and are cured. Eleven are in various stages of reexpansion and probably will be cured. Eight patients did not achieve reexpansion. Criteria were established retrospectively on an ongoing basis that indicate when pulmonary reexpansion is possible., Conclusions: These totally collapsed "entrapped" lungs expanded to fill the entire pleural space despite the presence of bronchopleural fistulas and an "open" pleura. Reexpansion was progressive, gradual, and dependent on improved compliance, clearing of bronchial inflammation and obstruction, and pleural cleansing. Criteria are established that identify those patients in whom complete reexpansion may take place and the disease may be cured.

The intrapleural instillation of agents for pleural sclerosis has proved effective in preventing the reaccumulation of symptomatic malignant pleural effusions. Because manufacture of the most popular agent, tetracycline, was recently discontinued, a preliminary study was undertaken to evaluate an alternative agent, doxycycline, for treating symptomatic malignant pleural effusions. From November 1991 to September 1992, 21 patients with symptomatic malignant pleural effusions have undergone overnight chest tube drainage followed by intrapleural instillation of 10 mL 1% lidocaine and then doxycycline, 500 mg in 30 mL 0.9% saline solution. The chest tube was clamped 2 hours with patient repositioning every 15 minutes. Tubes were removed when drainage was less than 50 mL/8 h. Of surviving patients, a complete objective response at 1 month was obtained in 88% (15/17), who were free of a symptomatic or radiographic recurrence of the effusion. Complications included mild pain in 23% (5/21), moderate pain requiring analgesics in 19% (4/21), and mild fever in 5% (1/21). There were no treatment-related deaths. The mean time for chest tube removal was 1.7 +/- 0.7 days after the last treatment. Based on this preliminary study, we conclude that doxycycline is a highly effective agent for the palliative treatment of symptomatic malignant pleural effusions. Its safety profile and efficacy compare favorably with those of tetracycline and other agents used for pleural sclerosis.

Support with extracorporeal membrane oxygenation (ECMO) can sustain life for a substantial period of time, but the role of long-term ECMO support is limited. The National Institutes of Health ECMO collaborative study revealed no significant reduction in mortality in adults with severe respiratory distress syndrome treated with ECMO. The value of ECMO in the treatment of transient, severe acute respiratory insufficiency has been demonstrated in patients after cardiac operations, in patients with Pneumocystis carinii pneumonia, and in patients following trauma. We present an example of refractory respiratory failure in a young asthmatic with massive atelectasis in whom the institution of ECMO allowed us to perform adequate pulmonary lavage. It resulted in improvement in gas exchange and the patient's survival.

Unilateral reexpansion pulmonary edema (RPE) is a rare complication of the treatment of lung collapse secondary to pneumothorax, pleural effusion, or atelectasis. Although RPE generally is believed to occur only when a chronically collapsed lung is rapidly reexpanded by evacuation of large amounts of air or fluid, in this review 15 of 47 cases of RPE available for assessment occurred when the pulmonary collapse was of short duration or when the lung was reexpanded without suction. The pathogenesis of RPE is unknown and is probably multifactorial. Implicated in the etiological process of RPE are chronicity of collapse, technique of reexpansion, increased pulmonary vascular permeability, airway obstruction, loss of surfactant, and pulmonary artery pressure changes. Since the outcome of RPE was fatal in 11 of 53 cases reviewed (20%), physicians treating lung collapse must be aware of the possible causes and endeavor to prevent the occurrence of this complication.