A bronchopleural fistula (BPF) is an abnormal communication between the bronchial tree and pleural space resulting in a high risk for morbidity and mortality. We descriemailbe a case highlighting the management of a BPF with subcutaneous and mediastinal air resulting in dysphagia and dysphonia using a technique that was first described in a 1992 CHEST article. The "Blowhole" technique may be utilized for patients that are poor surgical candidates requiring rapid correction and prevention of detrimental consequences such as pneumomediastinum, tension pneumothorax, upper airway compromise and pneumopericardium.
The increased use of computed tomography pulmonary angiography (CTPA) is often justified by finding alternative diagnoses explaining patients' symptoms. However, this has not been rigorously examined.We retrospectively reviewed CTPA done at our center over an eleven year period (2000 - 2010) in patients with suspected pulmonary embolus (PE). We then reviewed in detail the medical records of a representative sample of patients in three index years - 2000, 2005 and 2008. We determined whether CTPA revealed pulmonary pathology other than PE that was not readily identifiable from the patient's history, physical examination and prior chest X-ray. We also assessed whether the use of pre-test probability guided diagnostic strategy for PE.A total of 12,640 CTPA were performed at our center from year 2000 to 2010. The number of CTPA performed increased from 84 in 2000 to 2287 in 2010, a 27 fold increase. Only 7.6 percent of all CTPA and 3.2 percent of avoidable CTPAs (low or intermediate pre-test probability and negative D-dimer) revealed previously unknown findings of any clinical significance. When we compared 2008 to 2000 and 2005, more CTPAs were performed in younger patients (mean age (years) for 2000: 67, 2005: 63, and 2008: 60, (p=0.004, one-way ANOVA)). Patients were less acutely ill with fewer risk factors for PE. Assessment of pre-test probability of PE and D-dimer measurement were rarely used to select appropriate patients for CTPA (pre-test probability of PE documented in chart (% total) in year 2000: 4.1%, 2005: 1.6%, 2008: 3.1%).Our data do not support the argument that increased CTPA use is justified by finding an alternative pulmonary pathology that could explain patients' symptoms. CTPA is being increasingly used as the first and only test for suspected PE.
Over the last two decades nitric oxide (NO), a gas once regarded as a product of smog and an environmental irritant, has emerged as one of the most important molecules in biology. This L-arginine-derived product is found in serum, saliva, urine, and exhaled breath. It is recognized as the perfect cell-to-cell messenger since it is so lipophilic and readily diffuses across membranes. Moreover, through activation of guanylate cyclase and resultant cyclic guanosine monophospahate (cGMP) production, NO participates in the regulation of systemic and pulmonary vascular resistances (1), adhesion of platelets and neutrophils (2), and contraction of multiple organs including the heart, stomach, intestines, and uterus. It regulates transcription factor activation, translation of mRNAs controlling iron metabolism, glycolysis, mitochondrial electron transport, and protein acylation. On the one hand, excessive production of NO appears to contribute to the hypotension in septic shock and causes tissue damage in many chronic inflammatory diseases such as arthritis, glomerulonephritis, and diabetes (3). On the other hand, NO is effective in bacterial killing (4), downregulates the immune response (5), decreases oxidant injury, and protects cells against cytokine-induced injury and apoptosis (6). Thus NO, one of the simplest biosynthetic molecules, appears be both beneficial and toxic. The aim of this chapter764 Cohenis to shed insight into the confusing and often contradictory roles of NO in sepsis and in sepsis-induced myocardial dysfunction.
