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Proceedings of the British Thoracic Society, Scottish Thoracic Society and Thoracic Society of Australia Thorax: first published as 10.1136/thx.42.9.705 on 1 September 1987. Downloaded from Thorax 1987;42:705-752 Proceedings of the British Thoracic Society, Scottish Thoracic Society and Thoracic Society of Australia The 1987 summer meeting held on 1-3 July in the University of Edinburgh. Bronchoscopy in the elderly: helpful or hazardous? mg (two). Bronchoscopists completed questionnaires immediately afterwards, and patients the next day, AJ KNOX, BH MASCIE-TAYLOR, RL PAGE Respiratory returning them promptly by stamped addressed envelope. Medicine Unit, St. James's Hospital, Leeds Recently, After midazolam, fewer patients remembered the nasal doubt has been cast on the safety and desirability of spray (15% vs 36%, p<0.05) or bronchoscope insertion fibreoptic bronchoscopy in the elderly (Grant IBW, Br Med (9% vs 38%, p<0.01); complaints fell from 48% J 1986;293:286-7). To answer this question, we looked at previously to 7%o. Fewer patients were difficult to the safety and acceptability of the procedure in 60 patients, bronchoscope or found it unpleasant after midazolam, aged 80-92 over the four year period May 1982-May 1986. though more needed extra lignocaine; these differences Thirty-four patients were male. Sedation was with atropine, were not significant. Overall, the commonest complaint fentanyl, and diazepam, 2% lignocaine being instilled (32%) was of apprehension about the procedure or results locally over the cords. There was no serious morbidity and but 97%to would have another bronchoscopy, and 74%o no mortality. The diagnostic yield was similar to younger found it better than expected, though 93% appreciated age groups. Twenty-one patients had histologically proved being sedated. carcinoma of the bronchus, one a benign polyp, one tuberculosis diagnosed from washings, two collapsed lobes with re-expansion following removal of secretions. The copyright. remainder either showed infective changes or were normal. Visual distraction of biofeedback? Where no tumour was seen active treatment resulted in A study of patients' tolerance of fibreoptic bronchoscopy improvement in all but four. Of those with tumour, four were treated with radiotherapy with symptomatic relief, the PJV HANSON, MJ PLANT, J GOLDMAN, JV COLLINS St. remainder being treated conservatively. A positive Stephen's Hospital, London Anecdotal evidence suggests diagnosis of malignancy greatly helped the planning of that fibreoptic bronchoscopy is better tolerated by subjects future care. We conclude that fibreoptic bronchoscopy is a allowed to observe their bronchoscopy through a side http://thorax.bmj.com/ safe, useful procedure in this group of patients. viewing attachment. We conducted a controlled clinical trial on 73 patients undergoing bronchoscopy to assess the value of visual stimulation during the procedure. Standard A randomised, double blind comparison of midazolam and premedication was given and patients randomised to three diazepam -(Diazemuls) as sedation for fibreoptic groups: 23(S) looked at slides projected onto a screen; bronchoscopy 25(V) looked through the side viewing attachment and 25 controls (C) had no visual stimulation. The procedure was RG TAYLOR, F JOHNSON, JCG COX, PJH POI, AG conducted by an experienced bronchoscopist who delivered ARNOLD Medical Chest Unit, Castle Hill Hospital, a standard commentary on the basic anatomy seen during on September 26, 2021 by guest. Protected Cottingham Having shown that bronchoscopy patients the procedure. The side piece was attached for all groups dislike instrumentation of the nose and appreciate amnesia and used by the patient (Gp.V) or by an attendant (Gps. C (Morrison et al, Thorax 1987;42:223), we compared and S). Patients in group C used a hand control to project intravenous diazepam (as Diazemuls) with midazolam, slides onto a screen in front of them. Patient tolerance was which gives more amnesia at similiar sedation. One assessed by recorded cough counts and operator and patient hundred consecutive patients (median age 66.5 years) from questionnaires. Groups (S) and (V) coughed less than routine bronchoscopy lists were given atropine 0.6 mg controls (p<0.02; p<0.05 resp.). Group (V) found the beforehand, oxygen 2 I/min throughout and lignocaine by procedure more tolerable than (S) or (C) (p<0.05;< 0.001 nasal spray and endobronchially (up to seven 2 ml 2% resp.). Operator's assessment of patient tolerance related aliquots allowed). The initial dose of midazolam 3.5 mg inversely to degree of coughing in all groups. There was given over 30 s or diazepam 7.5 mg (1.5 min) was reduced generally no correlation between operator's and patient's by one third if the patient was small, frail or over 65 years. assessment of the procedure. Patients benefit subjectively, Increments of midazolam 0.5 mg or diazepam 1.25 mg were and cough less when using the sidepiece, perhaps due to repeated after 2 minutes as required until the patient was biofeedback. Patients also cough less but do not benefit drowsy with slurred speech; only then was the nose sprayed. subjectively from simple visual distraction as provided by The median (range) doses (and average ampoules/patient) slides. The operator considered both measures beneficial, were: midazolam 4 (2.5-10) mg (one), diazepam 10 (5-30) perhaps because of reduced coughing. 705 Thorax: first published as 10.1136/thx.42.9.705 on 1 September 1987. Downloaded from 706 Proceedings An assessment of fluid flux across the alveolar membrane immunologically or clinically but not confirmed using during bronchoalveolar lavage (BAL) conventional radiology. CT should also be performed before surgical resection to localise all aspergillomas. CA KELLY, J FENWICK, PA CORRIS, A FLEETWOOD, C WARD, DJ HENDRICK, EH WALTERS Departments ofMedicine, Physics and Biochemistry, Newcastle General Hospital, University Correlation of lung CT density with respiratory function in ofNewcastle on Tyne Two related studies were performed smokers and patients with bullous emphysema to investigate and quantify the degree of fluid exchange that might occur between the pulmonary circulation and the GA GOULD, W MACNEE, AT REDPATH, MF SUDLOW, JJK BEST, DC lung segment during BAL. Using 0.005% methylene blue as FLENLEY Rayne Laboratory, Departments of Respiratory a marker, we calculated the median degree of dilution of Medicine, Medical Physics, and Medical Radiology, the aspirate in five subjects with normal pulmonary Edinburgh We have previously shown a strong function undergoing 180 (3 x 60) ml BAL to be 24/o (range correlation between lung CT density and the severity of 15-35%). Using 99mtechnetium colloid it was 25% (range microscopic emphysema, using precise morphometric 16-35%), i.e. a net fluid gain of about 45 ml within the lung measurements of distal air space size to define emphysema segment. In the same experiment, four MBq of tritiated (Gould et al, Thorax 1986;41:717). Using the same method water were also added to the introduced fluid and the of CT analysis we have recorded the EMI number of the degree of dilution of tritium in the aspirate was found to be lowest 5th percentile of the CT density histograms (as a greater than that of the other two markers. This suggested measure of peripheral lung density) in 77 smokers (60M, that a median of 57 ml (range 36-130 ml) of water had 17F; 23-82 years; FEVY 15-125% predicted; Kco 15-139% effluxed from the lung during BAL. The total fluid gain by predicted) and 27 patients with bullous disease (25M, 2F; the lung was thus about 100 ml. We performed 3 x 60 ml 31-69 years; FEVY 15-84% predicted; Kco 20-114% BAL in a further five subjects 12 hours after an oral dose of predicted) correlating respiratory function with lung CT four MBq of tritiated water. A median of 39% (range density, excluding any bullous areas of the lung from 32-52%) of the 85 ml (range 63-124 ml) aspirated was analysis. In both groups lung CT density correlated with calculated to have come from the circulation by functional measurements thought to reflect the severity of simultaneously measuring the concentrations of tritium in emphysema, such as air flow limitation (FEV/FVC% plasma and aspirate. The concentration of urea, an predicted, r= -0.73) and impairment of gas transfer (CT 'endogenous marker', was also assayed simultaneously in density vs Kco r= -0.76). The extent of bullous disease plasma and aspirate, and fluid normally resident within the was not a major determinant of respiratory function. copyright. We lung segment was calculated to contribute only 2% of the conclude that 1) lung CT density correlates with functional total aspirate. These studies offer a quantitative analysis of impairment and thus quantifies the severity of emphysema, the complex fluid dynamics of a standard BAL. 2) impairment of respiratory function in patients with bullous disease relates mainly to the degree of emphysema in the non-bullous area of lung, 3) the combination of lung The early diagnosis of aspergilloma using computed CT density and gas transfer (Kco) measurements is http://thorax.bmj.com/ a tomography sensitive and specific method for non-invasively quantifying the severity of pulmonary emphysema. B STRICKLAND, KM CITRON, CM ROBERTS Departments of Diagnostic Radiology and Thoracic Medicine, Brompton Analysis of QCT lumbar spine densitometry values in Hospital, London The diagnosis of aspergilioma is made patients with obstructive lung disease from the chest radiograph and tomograph, which are imperfect methods for imaging damaged and distorted lung WJH LECKIE, M ALCOCK, P BALDOCK, A MCALINDON, S BURDON- parenchyma in which aspergillomas usually lie. The JONES, JM ROWLANDS, SDR HOMAN Thoracic Medicine Unit, diagnosis may thus be missed. We examined the CT The Queen Elizabeth Hospital, Woodville, South on September 26, 2021 by guest. Protected appearances in 26 patients referred with the diagnosis of Australia Vertebral fractures are common among older aspergilloma made or suggested by serum precipitins and a patients with chronic obstructive lung disease with (COLD) chest radiograph.
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