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Biomedical subjects

David Feller-Kopman

Publications and source records attributed to David Feller-Kopman.

At least 19 recordsLinked to original sources
PubMed2006

Expiratory abdominal rounding in acute dyspnea suggests congestive heart failure.

Patients in acute respiratory distress require rapid assessment of the cause of dyspnea. We have observed that many of those patients who are in congestive heart failure (CHF) exhibit rounding of the abdominal cross-section during expiration. We sought to evaluate the diagnostic utility of this breathing pattern in dyspneic patients presenting to an emergency department. Twenty-six subjects with dyspnea due to a variety of conditions were recruited from the emergency department at Beth Israel Deaconess Medical Center. Subjects ranged in age from 21 to 94 years and 81% were female. We measured variation in the anteroposterior and transverse diameters of the rib cage and abdomen using respiratory magnetometers and determined phase of respiration with a pneumotachometer. Investigators blinded to the subjects' identities and diagnoses interpreted measurements as indicating normal respiratory movement without expiratory abdominal rounding, slight expiratory rounding, or pronounced expiratory rounding. The likely cause of dyspnea was determined from discharge diagnoses in the medical record. Expiratory rounding was observed in 12/14 subjects with CHF and 5/12 subjects without CHF (p = 0.0186), and pronounced expiratory rounding was present in 11/14 patients with CHF and 2/12 patients without CHF (p = 0.0016). Test characteristics for the association of CHF with pronounced expiratory rounding were sensitivity 79%, specificity 83%, and predictive accuracy 81%. In patients with acute respiratory distress, expiratory abdominal rounding suggests CHF as the primary cause of dyspnea; a greater degree of rounding suggests a greater likelihood of CHF. The clinical utility of this diagnostic sign remains to be determined in a prospective study.

Abdomen↗
PubMed2006

The relationship of pleural pressure to symptom development during therapeutic thoracentesis.

STUDY OBJECTIVE: To describe the relationship of patients' symptoms during therapeutic thoracentesis to pleural pressure (Ppl). DESIGN: Review of prospectively collected data during 169 therapeutic thoracentesis procedures. SETTING: University Hospital in Boston, MA. PATIENTS AND METHODS: One hundred sixty-nine patients who had Ppl measured during therapeutic thoracentesis were included in this study. End-expiratory pressures were measured after the withdrawal of 5 mL of fluid and every 240 mL thereafter until the pressure was lower than -20 cm H(2)O, chest discomfort developed in the patient, or no more fluid could be removed. Patients' symptoms, including chest pain, chest discomfort, and cough were recorded simultaneously. RESULTS: There was no correlation between the amount of pleural fluid removed and the development of symptoms. The closing pressures and the total change in Ppl (see the "Materials and Methods" section for definitions), however, were significantly lower in the group of patients who experienced chest discomfort compared to patients who developed cough or were asymptomatic. There was also a trend toward a significantly lower pleural elastance in patients who developed cough compared to that in the other two groups. Additionally, only 22% of patients in whom chest discomfort developed, and 8.6% of patients in whom symptoms did not develop, had potentially dangerous Ppl values (ie, lower than -20 cm H(2)O). CONCLUSIONS: The development of chest discomfort is associated with a potentially unsafe drop in Ppl values and should be a sign to terminate thoracentesis. It is not necessary to terminate thoracentesis solely because of the development of cough. Without attention to pleural manometry, a significant percentage of patients may develop potentially dangerous Ppl. Although we recommend pleural manometry with all thoracenteses, when it is not used attention to symptoms remains a valuable surrogate.

Aged↗
PubMed2006

Ultrasound-guided thoracentesis.

Pleural effusions are an extremely common problem affecting approximately 1.5 million people in the United States each year. Over the last several years, the use of portable ultrasound machines has greatly enhanced the evaluation and management of patients with pleural disease. This article will review the relevant literature supporting the use of ultrasound for the evaluation of patients with pleural disease and address some practical practice management issues regarding ultrasonography.

Humans↗
PubMed2005

Tracheobronchomalacia: comparison between end-expiratory and dynamic expiratory CT for evaluation of central airway collapse.

PURPOSE: To compare dynamic expiratory and end-expiratory computed tomography (CT) for depicting central airway collapse in patients with acquired tracheobronchomalacia (TBM). MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was not needed. Retrospective review was performed of all patients with a CT diagnosis of TBM in a 10-month period (n = 34) who underwent evaluation of airway disease by means of three different sequences at multi-detector row CT: end inspiration, dynamic expiration, and end expiration (the latter was performed only at the levels of the aortic arch, carina, and bronchus intermedius). Fourteen patients (11 men, three women; age range, 19-79 years) who had comparable images obtained with all three sequences at any of these three levels were included in the study. The degree of airway collapse was measured by two thoracic radiologists in consensus by calculating the percentage change in the area of the airway between inspiratory and expiratory scanning. Statistical analysis was performed by using the paired t test. RESULTS: Dynamic expiratory CT elicited a significantly greater degree of airway collapse than end-expiratory CT at all three levels (P < .005). The mean percentages of airway collapse at each of the three levels were as follows: aortic arch, 53.9% with dynamic expiration versus 35.7% with end expiration (P = .0046); carina, 53.6% with dynamic expiration versus 30.9% with end expiration (P < .0001); and bronchus intermedius, 57.5% with dynamic expiration versus 28.6% with end expiration (P = .0022). CONCLUSION: Dynamic expiratory CT elicits a significantly greater degree of airway collapse than standard end-expiratory CT in patients with TBM.

Adult↗
PubMed2005

Microdebrider bronchoscopy: a new tool for the interventional bronchoscopist.

PURPOSE: We report our experience with a new airway tool, the microdebrider, in treating central airway obstruction. DESCRIPTION: From April 2002 to April 2004, 23 patients undergoing treatment of central airway obstruction were managed with the microdebrider. All procedures were done under general anesthesia with either a rigid bronchoscope (19 patients) or a suspension laryngoscope (4 patients). The microdebrider was used in an oscillating mode with rotation speeds of 1,000 to 3,000 rpm to resect obstructing tissue. EVALUATION: Fourteen patients (61%) had tracheal granulation tissue from prior intubation or tracheostomy, 6 (26%) had idiopathic subglottic stenosis, and 3 (26%) had malignant disease. Obstructing lesions were rapidly removed in all patients with interventions lasting between 2 and 15 minutes. There were no procedure-related complications. No patients required reoperation for airway obstruction in follow-up ranging from 1 to 24 months. CONCLUSIONS: Microdebrider bronchoscopy is a new technique that allows for precise, rapid, and safe removal of lesions obstructing the central airways. Complications of thermal modalities such as airway injury, tracheoesophageal fistulas, and airway fires can be avoided.

Adult↗
PubMed2005

Autofluorescence bronchoscopy and endobronchial ultrasound: a practical review.

Endobronchial ultrasound (EBUS) and autofluorescence bronchoscopy (AFB) are the two technologies to have the largest impact on diagnostic bronchoscopy in the last forty years. The AFB utilizes inherent tissue properties to identify preinvasive lesions of the central airways. The EBUS can accurately define airway invasion versus compression from tumors, guide transbronchial needle aspiration of hilar and mediastinal lymph nodes, and predict, based on ultrasound morphology, whether peripheral nodules are benign or malignant. It is also extremely useful for determining the proximal and distal extent of tumors in and around the airway, and aid in surgical planning. This article will review the principles and clinical applications of these two technologies.

Bronchoscopy↗
PubMed2005

Multislice CT evaluation of airway stents.

Tracheobronchial stents are playing an increasing role in the palliative treatment of large airway obstruction due to a variety of conditions, including extrinsic compression, intraluminal disease, and malacia. Computed tomography (CT) plays an important role in aiding planning of stent placement and in detecting various stent complications. In this pictorial essay, we illustrate and review the role of multislice CT in the pre- and post-stent placement settings. A special emphasis is placed upon the characteristic CT appearance of specific stent complications and upon the role of CT multiplanar reformations and 3-dimensional (3-d) reconstruction techniques.

Airway Obstruction↗
PubMed2005

Effect of clopidogrel with and without aspirin on bleeding following transbronchial lung biopsy.

BACKGROUND: Clopidogrel, a potent inhibitor of platelet aggregation, is being commonly prescribed in the elderly population due to its benefits in patients with atherosclerotic diseases. It is currently unknown whether clopidogrel increases the risk of bleeding during invasive pulmonary procedures. METHODS: Pigs of the Yorkshire species were randomized to one of the following two arms: clopidogrel (75 mg/d) alone; or clopidogrel plus aspirin (75 mg/d and 325 mg/d, respectively). The animals underwent flexible bronchoscopy with transbronchial lung biopsies under fluoroscopic guidance at baseline and after 1 week of daily oral intake of their assigned drugs. The main outcome of the study was the quantity of blood collected through the bronchoscope following transbronchial lung biopsy (TBLB). RESULTS: Sixteen animals were enrolled in the study, with 8 animals randomized to each arm. No statistically significant difference was found in the average quantity of blood resulting from transbronchial lung biopsies between procedures performed at baseline and those performed after animals received either clopidogrel (mean [+/- SD] dose, 1.41 +/- 1.14 mL) or clopidogrel plus aspirin (mean dose, 1.75 +/- 1.28 mL; p = 0.42). CONCLUSIONS: Clopidogrel, with or without aspirin, does not increase bleeding complications after TBLB in healthy pigs.

Animals↗
PubMed2005

Reducing maintenance and repair costs in an interventional pulmonology program.

BACKGROUND: In the current economic climate, hospitals and academic institutions demand that medical departments function in an efficient and cost-effective manner. Detailed business plans are necessary to build new clinical programs, and institutions have learned that new programs are associated with significant costs for purchasing and maintaining equipment. We report our experience with repairs to equipment before and after starting our interventional pulmonary (IP) program, and with the effect of an educational program on reducing these costs. METHODS: We retrospectively studied the costs of equipment repair in the 3 years preceding and in the 5 years following the development of an IP program in our institution, a university-based tertiary referral center. We also studied the effect of an educational program that was designed to enhance the skills of physicians and technical staff in handling the equipment. RESULTS: The cost of repairs to the equipment during the 3 years prior to the development of the IP program was $42 (US dollars) per procedure. In the initial 3 years following the start of the IP program, the yearly average cost rose 21% to $51 per procedure. After the introduction of the educational program, the yearly repair costs decreased by 84% to $8 per procedure. Based on our experience, we estimate that a reasonable budget for the cost of repairs is $50 per procedure. CONCLUSIONS: An educational program was effective in dramatically decreasing the costs of equipment repair after initiating an IP program. This is the first study to offer budgetary guidelines for equipment repair in an IP program and to demonstrate that an educational program can effectively reduce costs.

Costs and Cost Analysis↗
PubMed2005

Endoscopic removal of metallic airway stents.

BACKGROUND: Complications of metallic airway stents include granulation tissue formation, fracture of struts, migration, and mucous plugging. When these complications result in airway injury or obstruction, it may become necessary to remove the stent. There have been few reports detailing techniques and complications associated with endoscopic removal of metallic airway stents. We report our experience with endoscopic removal of 30 such stents over a 3-year period. METHODS: We conducted a retrospective review of 25 patients who underwent endoscopic stent removal from March 2001 to April 2004. The patients ranged in age from 17 to 80 years (mean, 56.3 years). There were 10 male and 15 female patients. The stents had been placed for nonmalignant disease in 20 patients (80%) and malignant disease in 5 patients (20%). All procedures were done under general anesthesia with a rigid bronchoscope. Special attention was focused on the technique of stent removal and postoperative complications. RESULTS: Thirty metallic airway stents were successfully removed from 25 consecutive patients over a 3-year period. The basic method of removal involved the steady application of traction to the stent with alligator forceps. In all cases, an instrument such as the barrel of the rigid bronchoscope or a Jackson dilator was employed to help separate the stent from the airway wall before removal was attempted. In some instances, the airway wall was pretreated with thermal energy prior to stent removal. Complications were as follows: retained stent pieces (n = 7), mucosal tear with bleeding (n = 4), re-obstruction requiring temporary silicone stent placement (n = 14), need for postoperative mechanical ventilation (n = 6), and tension pneumothorax (n = 1). CONCLUSIONS: Although metallic stents may be safely removed endoscopically, complications are common and must be anticipated. Other investigators have described airway obstruction and death as a result of attempted stent removal. Placement and removal of metallic airway stents should only be performed at centers that are prepared to deal with the potentially life-threatening complications.

Adolescent↗
PubMed2004

Central airway obstruction.

Central airway obstruction is a problem facing all medical and surgical subspecialists caring for patients with chest diseases. The incidence of this disorder appears to be rising because of the epidemic of lung cancer; however, benign causes of central airway obstruction are being seen more frequently as well. The morbidity is significant and if left untreated, death from suffocation is a frequent outcome. Management of these patients is difficult, but therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously. This review examines current approaches in the workup and treatment of patients suffering from airway impairment. Although large, randomized, comparative studies are not available, data show significant improvement in patient outcomes and quality of life with treatment of central airway obstruction. Clearly, more studies assessing the relative utility of specific airway interventions and their impact on morbidity and mortality are needed. Currently, the most comprehensive approach can be offered at centers with expertise in the management of complex airway disorders and availability of all endoscopic and surgical options.

Airway Obstruction↗
PubMed2004

Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency.

INTRODUCTION: Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist. OBJECTIVE: 1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety. DESIGN: A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents' psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires. RESULTS: During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures. CONCLUSIONS: The "see one, do one, teach one" model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.

Boston↗
PubMed2004

The natural history of radiographically occult bronchogenic squamous cell carcinoma: a retrospective study of overdiagnosis bias.

OBJECTIVE: An overdiagnosis bias occurs with the diagnosis of a disease that does not produce signs or symptoms before the patient dies from other causes. We sought to determine whether overdiagnosis bias is a factor when screening for squamous cell carcinoma of the lung. DESIGN: Retrospective study of the Miyagi Population-Based Lung Cancer Screening Registry for high-risk patients who were seen between January 1, 1982 (when sputum cytology tests were added for men with long smoking histories), and December 31, 1996. SETTING: Miyagi Prefecture, Japan. PATIENTS: A total of 251 patients (all men) who had sputum cytology test results that were positive for squamous cell carcinoma but had normal radiograph findings, 44 of whom declined cancer treatment (mean age, 70 years) and 207 of whom were treated with resection within 12 weeks of diagnosis (mean age, 65.5 year). END POINTS: Five-year and 10-year survival rates from primary lung cancer in both groups as of August 15, 2001. RESULTS: Among the 44 untreated patients, 15 (34%) remained asymptomatic. The survival rate due to primary lung cancer death in the untreated group was 53.2% at 5 years and 33.5% at 10 years. The survival rate among treated patients was 96.7% at 5 years and 94.9% at 10 years. Of the 125 treated patients who died, 14 (11.2%) died from primary lung cancer. CONCLUSION: Given that the two thirds of the untreated patients with squamous cell carcinoma of the bronchus died from lung cancer within 10 years, overdiagnosis bias does not appear to be a factor in screening for this disease. Thus, we recommend that patients with radiographically occult squamous cell carcinoma of the bronchus undergo tumor treatment after localization.

Aged↗
PubMed2003

Tracheobronchomalacia: evolving role of dynamic multislice helical CT.

Paired inspiratory and dynamic expiratory multislice CT imaging is a promising method for diagnosing TBM. A low-dose technique should be considered for the dynamic portion to reduce radiation exposure. Visual and quantitative analysis of the central airways provide a comprehensive assessment by allowing for the accurate diagnosis of TBM, determining its extent, assessing for predisposing conditions, and aiding selection of candidates for stent placement or tracheoplasty procedures. This technique can also be helpful for assessing response of airway dynamics following therapeutic intervention.

Bronchial Diseases↗
PubMed2003

Acute complications of artificial airways.

In conclusion, though there has been a dramatic reduction in the acute complications of artificial airways in the last hundred years, it remains crucial for the intensivist/anesthesiologist to have an implicit understanding of the anatomy and physiology of the process of ETI. As new techniques such as PDT are introduced, we must investigate their utility compared with the current standard of care in the most rigorous fashion. Additionally, as many of the complications of ETI can lead to increases in morbidity and mortality, prompt diagnosis and management are essential.

Humans↗