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Background: The novel influenza A (H1N1) pandemic affected South Africa late during the 2009 Southern hemisphere winter and placed an extra burden on a health care system already dealing with a high prevalence of chronic lung diseases and human immunodeficiency virus (HIV) infection., Aim: The aim of this study was to describe the epidemiological characteristics, clinical features, management and outcomes of patients with confirmed influenza A (H1N1) infection complicated by respiratory failure., Methods: We included all adult patients with confirmed influenza A (H1N1) infection that were referred to the medical intensive care unit of a large academic hospital in Cape Town for ventilatory support in this prospective observational study., Results: A total of 19 patients (39.5 +/- 14.8 years) needed ventilatory support over a 6-week period. Of these, 15 were female and 16 had identifiable risk factors for severe disease, including pregnancy (n = 6), type 2 diabetes mellitus (n = 6), obesity (n = 4), HIV infection (n = 3), immunosuppressive therapy (n = 3) and active pulmonary tuberculosis (n = 2). The most frequent complications were acute renal failure (n = 13), acute respiratory distress syndrome (n = 12) and ventilator associated pneumonia (n = 10). Thirteen patients died (mortality: 68.4%). Fatal cases were significantly associated with an APACHE II score >or=20 (P = 0.034), but not with a P(a)O(2)/F(I)O(2) <200 (P = 0.085) and a chest radiograph score >or=12 (P = 0.134)., Conclusion: The majority of patients with respiratory failure secondary to influenza A (H1N1) infection were young females and had an underlying risk factor for severe disease. The condition had a high mortality, particularly amongst patients with an APACHE II score >or=20.

Background: Emergency admissions with life-threatening haemoptysis in an area of high tuberculosis (TB) incidence at the University of Stellenbosch and Tygerberg Academic Hospital, South Africa. It is unclear if lung resection is regularly indicated to prevent recurrence following bronchial artery embolisation (BAE)., Objective: To prospectively evaluate risk factors for recurrence as selection criteria for surgery following embolisation: lack of complete cessation of haemoptysis, need for blood transfusion, presence of aspergilloma and absence of active TB., Design: Prospective interventional study with 1-year follow-up., Results: Within a 7-month period, 101 consecutive patients were admitted. Seven were excluded and 12 died shortly after admission. Haemoptysis ceased on medical treatment alone within 24 h in 21 of the remaining 82 patients. Their 1-year mortality was 10%. Eleven of 61 patients referred for emergency embolisation died before discharge. Of the 50 patients remaining at risk of recurrence, 38 (76%) were at low risk and 12 (24%) at high risk. Five of these patients (10% of those at risk) underwent surgery. Patients at low risk and operated patients had an uneventful course over 1 year, but two deaths occurred among the seven inoperable patients at high risk., Conclusion: Lung resection surgery following successful BAE for life-threatening haemoptysis can safely be avoided in patients at low risk of recurrence.

Smoking cessation is usually mentioned last in the chain of established measures to improve Tobacco Control. This seems logical, as smoking cessation is a secondary or tertiary preventative measure only. In the recently proposed Tobacco Control Scale (TCS) using 6 Tobacco Control measures pricing is considered most important, and smoking cessation least important. For current smokers secondary or tertiary preventative measures are necessary with smoking cessation being the most effective one as its impact on health is immediate. Pricing, on the other hand, is less effective in inciting current smokers to quit. Further, the vast majority of smokers would like to quit if they were able; so help in achieving this goal is welcome. Other Tobacco Control measures, on the other hand, are mostly negatively perceived by smokers because they perceive them as curtailment of their freedom. This is a psychological advantage the health professional active in this area has over other people involved in Tobacco Control and must be exploited. There is also strong evidence that smoking cessation is cost-effective, especially when comparing costs involved in addressing other important health risk factors, such as hyperlipidemia and arterial hypertension. Finally, the role of smoking cessation in helping to decrease social acceptability of smoking should not be underrated as every smoker who quits sets an example for other smokers to follow or for children not to start. In summary, smoking cessation continues to be of paramount importance among Tobacco Control measures, and should get more emphasis especially in health care settings.

The yield and safety of ultrasound (US)-assisted transthoracic fine needle aspirations (TTFNA) and cutting needle biopsies (CNB) in the setting of superior vena cava (SVC) syndrome are unknown. The aims of the present prospective study were to asses the diagnostic yield and safety of US-assisted TTFNA and CNB in SVC syndrome with an associated mass lesion abutting the chest wall. Over a 3-yr period, the present authors screened 59 patients with SVC syndrome, and enrolled 25 patients who had an associated mass lesion that extended to the chest wall. US-assisted TTFNA with rapid on-site evaluation (ROSE) was performed in all cases. CNBs were performed where a provisional diagnosis of bronchogenic carcinoma could not be established, and in 57.1% of patients with bronchogenic carcinoma (limited due to safety constraints). ROSE of US-assisted TTFNA confirmed diagnostically useful material in 24 patients, and cytological diagnoses were ultimately made in all of these cases (diagnostic yield 96%). US-assisted CNB had a diagnostic yield of 87.5%. Minor haemorrhage occurred in one out of 25 TTFNA and three out of 16 CNB. Neither procedure resulted in major haemorrhage nor pneumothoraces. US-assisted TTFNA and CNB have a high diagnostic yield and are safe in the setting of SVC syndrome with an associated mass lesion abutting the chest wall.

Ninety-eight emphysema patients were treated at 13 international sites during a 3-year series of single-arm, open-label studies with the IBV valve and a multi-lobar treatment approach. Fifty six percent of subjects had a clinically meaningful improvement in health-related quality of life, but standard pulmonary function and exercise studies were insensitive effectiveness measures. Quantitative CT analyses of regional lung changes showed lobar volume changes in over 85% of subjects. Lung volume reduction was an uncommon mechanism for a treatment response with bilateral upper lobe treatment. A redirection of inspired air, an interlobar shift to health-ier lung tissue, was the most common mechanism for a valve treatment response.

Questions Under Study: Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them., Methods: We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits., Results: At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse., Conclusion: A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient.

Beside pulmonary function tests, other measures of cardiopulmonary fitness have been shown to be useful for preoperative risk stratification. Reduced values of carbon monoxide lung diffusion capacity and its predicted postoperative value have been reported to be associated with postoperative complications and mortality. The most widely used low-technology exercise tests, which include 6 minutes of walking and stair climbing, have been reported to be valid predictors of complications. Patients with an impaired performance at these tests need to undergo a formal cardiopulmonary test with measurement of maximum oxygen consumption at cycle-ergometry or treadmill. Functional algorithms have been proposed that incorporate all these tests, with the aim to assist in defining the surgical risk.

The assessment of regional lung function to predict postoperative function is integral to preoperative evaluation of pulmonary resection candidates who have impaired lung function. The four validated ways are: anatomic calculation, split radionucleotide perfusion scanning with single photon emission CT (SPECT), quantitative CT scanning, and dynamic perfusion MRI. Estimations of predicted postoperative lung function based on anatomical calculations are the simplest, tend to overestimate postresectional functional loss, and should be performed in most operative candidates. Patients requiring further evaluation require one of the other techniques: SPECT, quantitative CT, or MRI. All effectively predict postoperative forced expiratory volume in 1 second (FEV1). Cost, local expertise and availability, and the need to predict postoperative VO maximum oxygen consumption (VO2 max) dictate the clinician's choice.

Background: Superior vena cava obstruction (SVCO) is commonly caused by neoplastic venous compression and presents with typical symptoms and signs. Its clinical severity presumably depends on the degree of obstruction and the adequacy of venous collateral formation., Objectives: The development of novel clinical and radiological scoring systems based on the postulate that a reproducible relationship exists between the degree of SVCO, the presence of collateral circulation and the extent of clinical symptoms., Methods: We prospectively evaluated consecutive cases of acute and subacute SVCO with a newly developed clinical scoring system, which is based on easily detectable clinical symptoms and signs of SVCO. In parallel, we recorded and scored the degree of SVCO and the extent of collaterals visible on contrast-enhanced computed tomography (CT)., Results: Thirty-four cases of SVCO were evaluated: 8 (23.5%) were clinically mild, 16 (47%) moderate and 10 (29.5%) severe. Lung cancer was the underlying histological diagnosis in 94% of cases. Radiologically, 53% had complete SVCO. A well-developed collateral system was found in 14 (41%). A scoring system subtracting a 'collateral score' from an 'obstruction score' showed a significant correlation with the clinical score (r = 0.75, p < 0.01)., Conclusions: Clinical severity of SVCO depends upon the degree of SVCO and is ameliorated by collateral formation. The novel clinical scoring system can predict the underlying CT features in SVCO and may be valuable in the bedside assessment of SVCO severity., (2007 S. Karger AG, Basel.)

At least 40% of all patients with pneumonia will have an associated pleural effusion, although a minority will require an intervention for a complicated parapneumonic effusion or empyema. All patients require medical management with antibiotics. Empyema and large or loculated effusions need to be formally drained, as well as parapneumonic effusions with a pH <7.20, glucose <3.4 mmol/l (60 mg/dl) or positive microbial stain and/or culture. Drainage is most frequently achieved with tube thoracostomy. The use of fibrinolytics remains controversial, although evidence suggests a role for the early use in complicated, loculated parapneumonic effusions and empyema, particularly in poor surgical candidates and in centres with inadequate surgical facilities. Early thoracoscopy is an alternative to thrombolytics, although its role is even less well defined than fibrinolytics. Local expertise and availability are likely to dictate the initial choice between tube thoracostomy (with or without fibrinolytics) and thoracoscopy. Open surgical intervention is sometimes required to control pleural sepsis or to restore chest mechanics. This review gives an overview of parapneumonic effusion and empyema, focusing on recent developments and controversies., (2008 S. Karger AG, Basel)

Background: Algorithms for the pre-operative evaluation of lung resection candidates with impaired lung function invariably include maximum oxygen uptake (VO(2)MAX) as a critical parameter of functional reserves, with a VO(2)MAX >or=20 ml/kg/min generally considered sufficient for pneumonectomy. Stair climbing is a low-cost alternative to assess exercise capacity., Objectives: As stair climbing is not standardised, we aimed to compare the altitude reached and the speed of ascent with VO(2)MAX measured by cycle ergometry., Methods: We prospectively enrolled 44 pulmonary resection candidates (mean age: 47.6 +/- 12.5 years) with an FEV(1) <80%. Patients were asked to climb as high and as fast as they could, to a maximum elevation of 20 m. The altitude reached and the average speed of ascent were compared to VO(2)MAX., Results: Forty-three patients reached a 20-metre elevation. Thirteen of them, as well as the patient who did not reach this height, had a VO(2)MAX <20 ml/kg/min. There was a linear correlation between speed of ascent and VO(2)MAX/kg (R(2) = 0.67), but not between altitude and VO(2)MAX/kg. All 24 patients with a speed >or=15 m/min had a VO(2)MAX >or=20 ml/kg/min. Thirty-nine of 40 patients with a speed >or=12 m/min had a VO(2)MAX >or=15 ml/kg/min., Conclusions: The average speed of ascent during stair climbing was an accurate semiquantitative predictor of VO(2)MAX/kg, whereas altitude was not. We were able to identify potential cut-off values for lobectomy or pneumonectomy. Pending validation with clinical endpoints, stair climbing may replace formal exercise testing at much lower costs in a large proportion of lung resection candidates., ((c) 2008 S. Karger AG, Basel.)

High prevalence of tuberculosis increases the odds for nonmalignant solitary pulmonary nodules (SPNs). Positron emission tomography (PET) using (18)F-fluorodeoxyglucose is the method of choice for the identification of malignant SPNs requiring curative surgery. However, PET is not widely available. Technetium-99m methoxy isobutyl isonitrile (MIBI) is inexpensive, widely available and shows increased uptake in malignant SPNs. The aim of the present study was to prospectively evaluate the diagnostic value of MIBI single photon emission computed tomography to distinguish between benign and malignant SPNs in a tuberculosis-endemic area. In total, 49 patients with radiologically indeterminate SPNs (single lesion < or =6 cm in diameter) were prospectively evaluated with MIBI. The final diagnosis was established with bronchoscopy, fine-needle aspiration, surgical resection or clinical follow-up for > or =2 yrs. A total of 12 (92%) out of 13 malignant lesions showed increased uptake of MIBI, while no uptake was observed in 33 (92%) out of 36 benign lesions. MIBI uptake indicated malignancy with a sensitivity and specificity of 92% and a negative predictive value of 97%. In this tuberculosis-endemic area, technetium-99m methoxy isobutyl isonitrile single photon emission computed tomography evaluation of solitary pulmonary nodules had a high negative predictive value. Therefore, it has the potential to prevent unnecessary surgical resections of benign nodules and serve as a low-cost alternative when positron emission tomography is not available.

Setting: Life-threatening haemoptysis is a frequent and often fatal complication in areas with a high prevalence of tuberculosis (TB). Bronchial artery embolisation remains the standard initial treatment. Subsequent curative measures, such as surgical resection of the focus of haemorrhage, are generally recommended to prevent recurrence, but risk-based selection criteria have not been established., Objectives: To identify risk factors for the recurrence of haemoptysis following embolisation., Design: Baseline characteristics were obtained from consecutive patients with life-threatening haemoptysis who were successfully embolised and followed up for at least 12 months., Results: Recurrence of haemoptysis was observed in 47% and was associated with increased mortality compared to patients without recurrence (31% vs. 10%, P = 0.021). Patients with recurrence experienced residual mild haemoptysis beyond the first week after embolisation (odds ratio [OR] 7.2), received blood transfusions (OR 5.3) or presented with an aspergilloma (OR 5.1). Conversely, the presence of active TB amenable to treatment (OR 0.3) protected patients from these events. Radiographic or angiographic appearance did not predict recurrence., Conclusions: Recurrence of haemoptysis following embolisation for life-threatening haemoptysis is common and is associated with high mortality. The results of this study can contribute to the risk assessment of these patients and guide decisions regarding the urgency of definitive therapy.

Background: Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1-9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion., Methods: We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis., Findings: No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0-0.54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1.2%), including one case of respiratory failure due to unexplained bilateral pneumothorax., Interpretation: Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.

The present study compared the diagnostic yield of ultrasound-assisted cutting-needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB) in chest lesions. A physician performed ultrasound and FNAB with a 22-G spinal needle in all patients, directly followed by a 14-G CNB in patients without contraindication. A total of 155 consecutive lesions arising from the lung (74%), pleura (12%), mediastinum (11%) or chest wall (3%) in patients with a final diagnosis of lung carcinoma (74%), other malignant tumours (12%), non-neoplastic disease (9%) or unknown (5%) were prospectively included. The overall diagnostic yield was 87%. Combined specimens were obtained in 123 lesions (79%). In these, yields of FNAB, CNB and both methods combined were 82, 76 and 89%, respectively. FNAB was significantly better than CNB in lung carcinoma (95 versus 81%) but CNB was superior in noncarcinomatous tumours and in benign lesions. On-site cytology was 90% sensitive and 100% specific for predicting a positive FNAB. One patient required drainage for pneumothorax (0.6%). Ultrasound-assisted fine-needle aspiration biopsy performed by chest physicians is an accurate and safe initial diagnostic procedure in patients with a high clinical probability of lung carcinoma. All other patients should undergo concurrent fine-needle aspiration biopsy and cutting-needle biopsy.

Background: Various formulations of nicotine replacement therapy are commercially available., Objectives: It was the aim of this study to test preference, safety and efficacy of a new nicotine mouth spray (1 mg/actuation; NicoNovum)., Methods: One hundred healthy smokers wanting to quit (mean age 43.1 +/- 11.2 years) were included. They were given the mouth spray, as well as 2-mg nicotine gums and nicotine oral inhalers to try out for 1 week. Subsequently, all participants were randomized into 3 groups - mouth spray (n = 50), gum (n = 25) and inhaler (n = 25) - and treated for 3 months., Results: Fifty-four of the hundred smokers preferred the spray, compared with 28 and 18 who preferred the gum and inhaler, respectively (p < 0.01 for spray vs. both the gum and inhaler). At 6 months, the sustained abstinence rates were 8 (16%), 5 (20%) and 2 (8%) for the mouth spray, gum and inhaler, respectively (p values = n.s.). Adverse effects (AEs) were mostly drug-related local symptoms, most frequently reported at the end of the tryout period: out of 106 drug-related AEs, 90 were due to the spray, 11 and 5 to the inhaler and gum, respectively. The three most frequent AEs were almost exclusively caused by the spray: burning of the tongue/throat reported by 35, nausea by 18, and hiccup by 16 participants., Conclusions: Participants preferred the mouth spray over the gum and inhaler, but its use was coupled with a high rate of local AEs. The efficacy of the mouth spray seemed comparable with the one obtained by the gum and inhaler. Further studies are necessary to show whether a reduction in the dose per actuation to about 0.5 mg would result in less side effects, which in turn might yield higher long-term drug compliance and possibly higher success rates than the ones achieved with other forms of nicotine replacement therapy.

Transbronchial needle aspiration is a bronchoscopic sampling method for a variety of bronchial and pulmonary lesions. The present study investigated whether and how serial needle passes contribute to the yield of transbronchial needle aspiration at specific target sites. A total of 1,562 needle passes, performed at 374 target sites in 245 patients with neoplastic disease (82%), non-neoplastic disease (15%) or undiagnosed lesions (3%), were prospectively recorded and rated for anatomical location, size, bronchoscopic appearance and underlying disease. Positive aspirates were obtained in 75% of patients and at 68% of target sites. A diagnosis was established with the first, second, third and fourth needle pass at 64, 87, 95 and 98% of targets, respectively. The absolute yield varied strongly with target site features, but the stepwise increment to the maximum yield provided by serial passes was similar across target sites. In conclusion, three transbronchial needle passes per site are appropriate when only a tissue diagnosis is sought and when alternative sites or sampling modalities are available. At least four or five passes should be carried out at lymph node stations critical for the staging of lung cancer.

The immune responses against pulmonary tuberculosis are still poorly defined. This study describes changes in leucocyte and lymphocyte subsets during treatment to find reliable immunological markers for the disease and treatment response. Flow cytometric peripheral blood immune phenotyping, routine haematology and sputum microbiology were performed on 21 HIV-negative adult tuberculosis (TB) patients with positive sputum cultures during therapy in comparison with 14 healthy purified protein derivative (PPD)-positive volunteers. Patients at diagnosis showed high absolute neutrophil and monocyte counts which fell during treatment but low lymphocyte subset counts which increased [except natural killer (NK) and NK T cells]. High counts of a population of CD3(dim)/CD56+ NK T cells at diagnosis correlated significantly with negative sputum culture after 8 weeks of treatment. A multivariate classification technique showed improved correlation when NK cells were taken into account. In conclusion, peripheral blood white cell counts change significantly during treatment and counts at diagnosis, especially CD3(dim)/CD56+ NK T cells, hold promise in predictive models of TB treatment response.

Minimally invasive diagnostic and therapeutic approaches in medicine have been applied for a more selective and tailored approach to reduce patients' morbidity and mortality. The efficacy of interventional pulmonology for palliation of patients with central airways obstruction has been established and its curative potential for intralesional treatment of early cancer has raised great interest in current screening programmes. This is due to the fact that surgical resection and systemic nodal dissection as the gold standard is relatively morbid and risky, especially when dealing with individuals with limited functional reserves due to smoking-related comorbidities, such as chronic obstructive pulmonary disease. Furthermore, such comorbidities have been proven to harbour early stage lesions of several millimetres in size without involvement of nodal disease that may be amenable to local bronchoscopic treatment. Therefore, the success of minimally invasive strategies for palliation and treatment with curative intent strongly depends on the diligent identification of the various factors in lung cancer management, including full comprehension of the limits and potential of each particular technique. Maximal preservation of quality of life is a prerequisite in successfully dealing with individuals at risk of harbouring asymptomatic early lung cancer, to prevent aggressive surgical diagnostic and therapeutic strategies since overdiagnosis remains an issue that is heavily debated. In the palliative setting of alleviating central airway obstruction, laser resection, electrocautery, argon plasma coagulation and stenting are techniques that can provide immediate relief, in contrast to cryotherapy, brachytherapy and photodynamic therapy with delayed effects. With curative intent, intraluminal techniques that easily coagulate early stage cancer lesions will increase the implementation of interventional pulmonology for benign and relatively benign diseases, as well as early cancer lesions and its precursors at their earliest stage of disease.

Physicians increasingly use transthoracic ultrasound (US) as an aid for diagnostic procedures. At the bedside, US helps to visualize neoplasms in the chest wall, pleura, peripheral lung, and anterior mediastinum involving or abutting the pleura. Histology specimens from cutting-needle biopsies have been shown to be safe and effective. This prospective study determined the yield and safety of US-guided fine-needle aspiration biopsy (FNAB) as a first-line bedside investigation. We recruited 97 consecutive patients, and of these, 85 underwent both cutting-needle biopsy and FNAB. These were adequate for diagnosis in 81.2% and 80% of cases, respectively, with a combined yield of 90%. Measured with a novel semiquantitative score, FNAB allowed a diagnosis with fewer special investigations than cutting biopsy. US-guided FNAB by pulmonologists performed best in lung carcinoma and can be recommended as a first-line investigation in patients with a high clinical suspicion of this diagnosis., (Copyright 2005 Wiley-Liss, Inc)

Objective: Little evidence supports the commonly recommended 2-week duration for an oral corticosteroid trial in stable COPD patients. We aimed to assess the time to spirometric and exercise responses in stable COPD patients undergoing an oral corticosteroid trial., Methods: In a pilot study a 28-day trial with prednisone 0.5 mg/kg bodyweight was performed in all outpatients meeting entry criteria during one calendar year. Response was assessed by spirometry (twice weekly) and 6-minute walk distance (6MWD, weekly). Of 36 moderate to severe COPD patients started on prednisone, 30 completed the study according to the protocol., Results: The mean post-bronchodilator forced expiratory volume in 1 second (FEV1) was 49.5% predicted and the 6MWD was 444 m at baseline. On the basis of spirometry (post-bronchodilator FEV1 > or = 15% and > or = 200 ml) 12 patients were responders. Five additional patients improved their 6MWD by > or = 55 m (exercise responders). Of all 17 responders six (35%) responded between day 17 and 28 (4 spirometric and 2 exercise responders). Responders and non-responders showed a maximum FEV1 increase from baseline on day 24 of 264 ml and 70 ml, respectively., Conclusion: An oral corticosteroid trial of only 2 weeks' duration may miss a clinically significant number of corticosteroid-responsive stable COPD patients.

Purpose of Review: Pulmonary resection remains the only curative treatment option for lung cancer surgery. This review summarizes recent advances in the preoperative functional evaluation of the patient with lung cancer., Recent Findings: The workup of patients with bronchogenic carcinoma covers three areas: tumor type, tumor extent, and patient cardiopulmonary reserves. Significant advances have been made in the latter two areas. Traditionally lobectomy was regarded as the minimum resection for lung cancer; new studies are challenging this view and suggesting that segmentectomy is acceptable for stage Ia cancers < or =20 mm. An important change relating to cardiopulmonary reserves of the patient is the shift in emphasis toward early exercise testing and, in particular, the use of stair climbing as a surrogate marker of maximal oxygen consumption. New studies confirm the benefit of combined lung volume reduction surgery and lung cancer surgery in certain patients who might otherwise be excluded from surgery because of poor lung function., Summary: Advances in the preoperative workup of lung cancer patients and in surgical techniques are permitting resections in previously inoperable patients. A new, simplified algorithm for the preoperative workup of lung cancer patients assessing the value of stair climbing as a surrogate marker of maximal oxygen consumption is proposed.

Purpose of Review: Transthoracic ultrasound has received increased interest from chest physicians in recent years. Modern ultrasound devices are user friendly, inexpensive, lightweight, and portable, which makes them suited for outpatient settings as well as for bedside investigation of the severely ill. Ultrasound is set to become a practical and essential tool for the pulmonologist in the near future., Recent Findings: An ever-increasing number of articles are aimed at describing and refining how ultrasound can be utilised by chest physicians in daily practice. Only basic ultrasound skills are required to assess pleural effusions and perform ultrasound-guided thoracocentesis. Sonographic assistance with insertion of chest drains as well as identification or biopsy of thoracic masses are more complex, and advanced skills are required for the investigation of pneumothorax and thromboembolic disease., Summary: The current literature documents the progress in the application of ultrasound for the practicing chest physician. In this article the authors describe the most recent developments and follow up with some simple but essential advice for the novice venturing into chest ultrasound.

Background: Rapid on-site evaluation has been proposed as a method to improve the yield of transbronchial needle aspiration., Objectives: This study investigated whether on-site analysis facilitates routine diagnostic bronchoscopy in terms of sampling, yield and cost., Methods: Patients with lesions accessible for transbronchial needle aspiration on computed tomography were investigated. A cytopathologist screened the needle aspirates on site for the presence of diagnostic material. The bronchoscopic sampling process was adjusted according to the results. In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung tumours or lymph node sites (mediastinal: 7%; tracheobronchial: 68%; other: 25%). In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung lesions (paratracheal tumours or lymph nodes: 7%; tracheobronchial lymph nodes: 68%; other: 25%)., Results: The diagnostic yield of needle aspiration was 77 and 25% in patients with neoplastic and non-neoplastic lesions, respectively. Sampling could be terminated in 64% of patients after needle aspiration had been performed as the only diagnostic modality, and on-site analysis identified diagnostic material from the first site aspirated in 50% of patients. Only in 2 patients (2%) diagnostic aspirates were not recognized on site. On-site analysis was cost effective due to savings for disposable diagnostic tools, which exceeded the extra expense for the on-site cytology service provided., Conclusions: Rapid on-site analysis of transbronchial aspirates is a highly useful, accurate and cost-effective addition to routine diagnostic bronchoscopy., (Copyright (c) 2005 S. Karger AG, Basel.)

Background: Transthoracic ultrasound (US) has gained popularity as a tool for visualizing pleural effusions and assisting thoracentesis or chest drain placement. In the absence of effusion, US just as well demonstrates solid masses involving or abutting the pleura, yet biopsy of such lesions is not widely performed by chest physicians., Objective: To assess the feasibility and the safety of US-assisted cutting needle biopsy performed by chest physicians in routine practice., Methods: Lesions involving or abutting the pleura > or =20 mm in diameter on US were sampled with a 14-gauge cutting needle under local anesthesia. Biopsy site, needle direction and depth of penetration were determined with US. The procedure was performed without direct US guidance in 'free-hand' technique., Results: Ninety-one patients underwent 96 cutting-needle biopsies for suspected peripheral lung tumors (n = 44, 46%), pleural-based (n = 39, 41%), mediastinal (n = 10, 10%), or chest wall lesions (n = 3, 3%), which were single in 71%, multiple in 6% and diffuse in 23%. Sensitivity for malignant neoplasms (n = 65) was 85.5% and 100% for mesothelioma (n = 10). Pneumothorax occurred in 4%., Conclusions: US-assisted cutting-needle biopsy of lesions > or =20 mm in diameter is safe in the hands of pulmonologists. The yield for neoplastic disease including mesothelioma is high.

Aims: To determine whether 2-week pre-treatment with transdermal nicotine influences withdrawal symptoms or success rate of subsequent smoking cessation using nicotine patches., Design: Randomized controlled trial., Setting: Smoking cessation clinic., Participants: Healthy smokers (n = 200, 45% female) were allocated randomly to either active nicotine-patch (AP, 15 mg daily, n = 100) or placebo-patch (PP, n = 100) pre-treatment. Baseline characteristics were well balanced except for daily cigarette consumption: mean (+/- SD) 23.1 (8) and 26.4 (11) for AP and PP groups, respectively (P = 0.021)., Intervention: At the screening visit (-2 weeks) subjects were counselled and started pre-treatment with daily patches (AP or PP). From the quit date (week 0) onwards all subjects received active nicotine patches for 12 weeks (15 mg daily for 8 weeks, 10 and 5 mg daily for 2 weeks each) and counselling., Measurements: Follow-up visits included measurement of exhaled carbon monoxide at the quit date, 2, 6, 10 and 26 weeks. Subjects documented daily cigarette consumption and severity of withdrawal symptoms (Wisconsin scale) from -2 weeks to week 2. Outcome measures were withdrawal symptoms composite score and abstinence rates., Findings: There was no significant difference in withdrawal symptoms, but more subjects in the AP group were smoke-free during the 6-month study period. Overall sustained abstinence was documented in 17% of subjects at 6 months; 22% and 12% for AP and PP, respectively (P = 0.03). Retrospective subgroup analysis showed for subjects smoking >16 cigarettes/day sustained cessation rates were 22% and 9% for AP and PP, respectively (P = 0.01). No difference in adverse event rates was observed., Conclusions: Nicotine patch pre-treatment before cessation did not reduce early withdrawal symptoms but increased sustained abstinence rates at 6 months. The nicotine pre-treatment was equally effective in light and heavy smokers.

Background: The Polyflex is a commercially available silastic airway stent with proven efficacy. Due to a smooth outer surface its anchorage in the airway wall is superficial which may lead to stent migration., Objective: To study the performance of an newer version of the Polyflex stent with a studded outer surface, which should improve anchorage., Methods: In a 5-centre international study the new stent was prospectively tested in symptomatic patients with neoplastic central airway stenosis of more that 50% of normal diameter. Insertion technique, efficacy of stent placement and stent-related complications were recorded before, 1 month and 3 months post stent placement., Results: Under general anaesthesia and rigid bronchoscopy 27 stents were inserted in 26 patients, mean age: 62 years (range: 37-83), 16 men. Diagnoses were 18 bronchogenic carcinoma, 4 oesophageal carcinoma, 2 metastases, 1 tracheal carcinoma, and 1 schwannoma. The stents were inserted in the following locations: 10 right main bronchus, 8 left main bronchus, 7 trachea, and 2 tracheo-bronchial. There was significant improvement in all functional parameters assessed from before (A), to 1 month (B) and 3 months (C) after stent placement. The measured values (mean +/- SD) were for the WHO scale: A: 2.7 (0.8), B: 1.5 (0.9), C: 1.6 (1.0); for the Karnofsky scale: A: 44 (19), B: 72 (18), C: 71 (21); for the Dyspnoea Index: A: 3.3 (0.7), B: 1.5 (0.8), C: 1.9 (1.2); for FEV(1): A: 1.2 (0.5), B: 1.9 (0.6), C: 1.5 (0.5), and for FVC: A: 2.1 (0.7), B: 2.8 (0.7), C: 2.5 (1.0). Stent-related complications were 4 reversible stent obstructions by secretions, 1 migration. The observation period was mean 4.3 months (range 2 days to 23 months)., Conclusion: The studded Polyflex showed excellent efficacy, was very well tolerated, and had a very low migration rate. It presents an improvement over the older smooth model and can be considered a true alternative to the most widely used silastic stent, the Dumon stent., (Copyright 2004 S. Karger AG, Basel)

Thoracoscopy is the most accurate yet most expensive tool for establishing the diagnosis of tuberculous (TB) pleurisy. However, most high TB-incidence regions have limited financial resources, lack the infrastructure needed for routine thoracoscopy and require an alternative, cost-effective diagnostic approach for pleural effusions. Altogether, 51 patients with undiagnosed exudative pleural effusions were recruited for a prospective, direct comparison between bronchial wash, pleural fluid microbiology and biochemistry (adenosine deaminase (ADA) and cell count), closed needle biopsy, and medical thoracoscopy. The final diagnosis was TB in 42 patients (82%), malignancy in five (10%) and idiopathic in four patients (8%). Sensitivity of histology, culture and combined histology/culture was 66, 48 and 79%, respectively for closed needle biopsy and 100, 76 and 100%, respectively for thoracoscopy. Both were 100% specific. Pleural fluid ADA of > or = 50 U x L(-1) was 95% sensitive and 89% specific. Combined ADA, lymphocyte/neutrophil ratio > or = 0.75 plus closed needle biopsy reached 93% sensitivity and 100% specificity. A combination of pleural fluid adenosine deaminase, differential cell count and closed needle biopsy has a high diagnostic accuracy in undiagnosed exudative pleural effusions in areas with high incidences of tuberculosis and might substitute medical thoracoscopy at considerably lower expense in resource-poor countries.

Lung resection remains the treatment of choice in the curative approach to nonsmall cell lung cancer. Because most lung cancer patients are current or former smokers, they are at increased risk of chronic obstructive pulmonary disease and coronary artery disease, conditions associated with increased surgical morbidity and mortality. Careful preoperative assessment of the cardiopulmonary reserves is therefore of great importance. Various single and combined parameters for the functional assessment before surgery have been proposed. Currently the emphasis is on the determination of forced expiratory volume in the first second, the diffusing capacity for carbon monoxide, and exercise testing with the measurement of maximal oxygen uptake. Adherence to established algorithms for this preoperative evaluation, advances in operative technique (video-assisted thoracoscopic surgery and combined operations of lung cancer surgery with lung volume reduction surgery), and perioperative care permit resections in patients who until recently would have been considered functionally inoperable.

Background: The performance of spirometers is often evaluated under ideal conditions with computer-generated waveforms or in vivo testing with healthy subjects. Real-life conditions are less ideal because of comorbidities, age of the subjects, and a variety of air flow limitations. Evaluation of new spirometry equipment can also be performed under these less favorable conditions. The Spirospec is a new desktop spirometer that is commercially available, but its accuracy has not been evaluated in a clinical setting., Objective: Test the Spirospec with subjects with normal and pathologic pulmonary function., Methods: A group of 45 patients (mean age 38.4 years, 27 male) booked for evaluation in the pulmonary function laboratory of a tertiary care university hospital were tested with both a Spirospec and a standard Jaeger Masterlab 4.0 spirometer, according to the guidelines of the American Thoracic Society. Three subgroups (normal spirometry, obstructive air flow limitation, and restrictive air flow limitation) of 15 consecutive subjects each underwent spirometry., Results: Pulmonary function measurements from the Spirospec correlated closely (r = 0.95-0.99) with those from the Masterlab 4.0, showing good limits of agreement and differences between the 2 devices: forced vital capacity 0.03 L, forced expiratory volume in the first second (FEV(1)) -0.01 L, peak expiratory flow -0.41 L/s, peak inspiratory flow 0.43 L/s, forced expiratory flow at 50% of total lung capacity 0.13 L/s, and forced expiratory flow at 75% of total lung capacity 0.12 L/s. With the exception of forced vital capacity and FEV(1), these differences were statistically significant (p < 0.05)., Conclusion: The Spirospec is comparable to the Masterlab 4.0, with high accuracy for FEV(1) and forced vital capacity and clinically acceptable differences in the measured flow variables.

We report the case of a 51-year-old woman with a large cell bronchial carcinoma with neuroendocrine differentiation (T3N0M0, stage IIB) and bilateral exophthalmos. A CT of the orbitae was compatible with Graves ophthalmopathy, but neither abnormalities in thyroid function nor thyroid antibodies could be found. The proptosis normalized 10 days after tumor resection. We conclude that the most likely cause of the reversible proptosis in this patient is paraneoplastic, a condition not previously described in the English-language literature.