SPN

79 year old female non smoker presented with hypercalcemia and a low PTH. She was pan-ct'd and all that came up was this SPN in the RML:

It's size is about 7 mm. Of note, the CT slices were 7 mm.
How would you proceed?

Digging for gold

This nice woman with mild asthma lost a tooth crown and aspirated it as she was about to have lunch.

Check out the CxR. It was lodged at the first branching of the R bronchus intermedius with the smooth side (the shiny top of the crown) up towards us. Unfortunately I was using an optic (as opposed to digital, I know they are all "optic") scope and couldn't take a picture. I did snap a picture of the crown after removal with the basket on the side.

We did not have a bronch basket handy so an OR gallstone basket was just the perfect sixe.

BAL in suspected VAP

A few years ago, Fagon et al published a large trial of BAL for evaluation of VAP in over 400 ICU patients in France. Compared to a noninvasive strategy, an invasive strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.
Recently a trial was published on the NEJM comparing quantitative BAL to endotracheal aspiration with nonquantitative culture of the aspirate. They found no significant difference in the primary outcome (28-day mortality rate), the rates of targeted therapy, days alive without antibiotics, maximum organ-dysfunction scores, length of stay in the ICU or hospital.
What is your routine practice in the ICU for VAP? Do you bronch everybody with suspected VAP?
(Dr. Kollef had an interesting editorial on the Canadian trial in the same issue of the NEJM).

TORCH trial

The TORCH trial is the lead article on today's NEJM. No statistically significant change in mortality with Advair but reduced annual rate of exacerbations and improved health status and spirometric values. There was also an increase in pneumonias in the fluticasone-treated groups (FP alone or Advair).
How do you think this data will affect your prescribing patterns for ICS in COPD?

Propofol for bronchs

I had posted a long time ago on sedation for bronchs and our preference for propofol. I am at a new hospital and looking to implement a similar protocol (propofol is now generic and much cheaper than a Versed/opiate combo) and in my experience provides more predictable and reliable sedation.
1. Have you used propofol for bronchs?
2. If not what is your default?
3. Do you have any data on either? I have found the following references in support of propofol is somewhat more obscure sources:
1: Acta Anaesthesiol Scand. 2003 Apr;47(4):411-5. Should patients undergoing a bronchoscopy be sedated? Gonzalez R, De-La-Rosa-Ramirez I, Maldonado-Hernandez A, Dominguez-Cherit G.
2: Anasthesiol Intensivmed Notfallmed Schmerzther. 2004 Oct;39(10):597-602. Sedation for fiberoptic bronchoscopy: fewer adverse cardiovascular effects with propofol than with midazolam. Ozturk T, Cakan A, Gulerce G, Olgac G, Deren S, Ozsoz A.
3: Anesth Analg. 2002 May;94(5):1212-6, table of contents. Target-controlled versus manually-controlled infusion of propofol for direct laryngoscopy and bronchoscopy. Passot S, Servin F, Allary R, Pascal J, Prades JM, Auboyer C, Molliex S.

Allergy shots

The Cochrane database recently published this review on allergy shots for rhinitis. They retrieved 1111 publications of which 51 satisfied their inclusion criteria (looking for RCTs with placebo-control) and in total there were 2871 participants (1645 active, 1226 placebo), each receiving on average 18 injections.
Duration of immunotherapy varied from three days to three years. Symptom score data from 15 trials were suitable for meta-analysis and showed an overall reduction in the immunotherapy group and medication score data from 13 trials also showed an overall reduction in the immunotherapy group.
It is good to see some good quality data on that. However, I was amazed by the number of shots. Where I was in practice patients would be on weekly or monthly shots for 3, 4, 7 years and would be way over these limited numbers.
What has your experience been with allergy shots?

Low DLCO

Here is a submission from John B: It is interesting that it is close to the very first post of this blog.

I continually test a low (60% I think) DLCO on a PFT. All other parts of that test are normal.
I have dizziness, lightheadedness, sob (random- at rest or exertion). Palpitations at times, but not nearly as often as in the past.
Occasional feeling of pressure in chest. Echo was normal, but imo it looks like values have been increasing over the past 2 years- still in normal ranges, but I do show some trace/mild tricuspid regurg and trace mitral regurg.
Two times I have done a cardiopulmonary stress test, and both times it shows a cardiovascular limitation evidenced by crossing of the anaerobic threshold earlier than I should- metabolic acidosis after exertion.
Nuclear stress test shows no blockages.
Also, my own testing with a pulse oximeter seems to indicate occasional drops in my O2 to as low as 92, but then quickly recovering to 96-98. This has never happened in doctor's office with their oximeters, so I don't know if mine is accurate (however, when testing my wife as a control subject, she always shows 96-98).

high-res CT scan of chest - normal (6 months ago)
non-invasive ct angiography (body scan) - normal lungs / lung blood vessels (1+ year ago)
- calcium score was 0 (2 years ago)

multiple echocardiograms are in normal range but show trace / mild regurgitation
- cardiopulmonary stress test shows a cardiovascular limitation evidenced by a metabolic acidosis at peak exercise
- low DLCO (+-60% of predicted - 1 month ago)
- nuclear stress test shows no blockages (1.5 years ago)
- triglycerides 270 - vldl 56 - ldl 240 - hdl 36)
- lyme disease- treated with abx in past

No one knows what to make of this. I was thinking of requesting a stress echo, to see if there is more regurgitation after exercise.
Any other tests I should have done? Would really appreciate some assistance. I can provide more specific data if needed.

-John

Chest tube care

We are re-vamping our group's chest tube standard orders and I was wondering how people like their chest tubes handled.
What do you use for sedation/pre-medication for a non-emergent chest tube placement?
How often do you like the dressing changed?
What do you tell the nursing staff to do in case of CTs accidentally coming out?
I thought about calling this post "Zen and the art of chest tube maintenance" but I didn't know if the joke would go well...

C. diff, C. diff run, run diff run

This is more of a critical care (or general care, if you will) than true pulmonary.
I have been seen a lot of docs (including some ID) treating uncomplicated C. diff colitis with PO vanco up front instead of Flagyl. Have recommendations changed? Do you use much PO vanco?

Alternatives to surgery

Following Jeff's question on therapy for lung Ca in octogenarian (see post below) I just saw a patient in a similar situation. This is an 85 y/o woman with a recent spiro revealing an FEV1 of 600 ml. She was just diagnosed with a 2-cm LUL adenoCa with no adenopathy and no other distant disease on PET. She is still fairly active but stated that even if her lung function improved, she would not want surgery.
With such a low FEV1 and with some risk of further loss of function with radiation, what would you suggest? And following on JJ's question, what are your alternatives for octogenarians (or anybody else) who can't or won't have surgery?