CAPES / A análise da mecânica respiratória possibilita verificar o funcionamento pulmonar e as possíveis alterações por alguma complicação ou lesão do pulmão. A análise da gasometria arterial é importante nos ajustes dos parâmetros ventilatórios, possibilitando verificar complicações relacionadas à ventilação. O objetivo principal deste estudo é associar os parâmetros físicos e funcionais do pulmão de crianças de 0 a 1 ano sob ventilação mecânica invasiva no pós-operatório de cirurgia cardíaca através da análise dos parâmetros ventilatórios e da mecânica respiratória com o procedimento radiográfico convencional. No total, 46 crianças foram analisadas nesta faixa etária, porém somente aquelas que apresentaram padrão respiratório e radiografias representativas de atelectasia e derrame pleural foram selecionadas. Das 30 crianças selecionadas, 10 apresentam atelectasia e 8 derrame pleural (DP). Os dados analisados são de antes e após o surgimento da complicação pulmonar. Os dados das crianças que não apresentaram nenhuma complicação inicialmente foram utilizados para verificar a possibilidade da análise da mecânica respiratória através dos ciclos controlados e a sua relação com os dados da gasometria arterial. Foram coletados dados da mecânica respiratória através do monitor gráfico Inter® GMX e do programa Wintracer e a análise da área do pulmão pela radiografia através do AutoCad® 2012. A análise das ondas controladas do ciclo respiratório em modo assistido controlado dos recém-nascidos mostra que o pH não se altera, em relação ao valor esperado normal. Todos os parâmetros da mecânica respiratória apresentaram alteração entre os estados sem e com complicação pulmonar. Os grupos com atelectasia apresentou significância estatística para redução nos parâmetros de volume corrente (VC), área do pulmão (AP) e pressão parcial de oxigênio arterial (PaO2) e aumento em frequência respiratória (FR) e Tempo em ventilação mecânica invasiva (VMI). No grupo DP a redução foi significativa em AP e houve aumento significativo do Tempo em VMI. Os valores de complacência ficaram abaixo da normalidade para a idade e de resistência acima dos valores considerados normais em todos os grupos. Os resultados do coeficiente de Spearman (ρ) que apresentaram significância estatística entre a AP com os parâmetros pulmonares foram para o grupo com atelectasia no parâmetro de resistência das vias aéreas (RVA) (ρ= -0,648 e P=0,043) e para o grupo com DP no parâmetro complacência estática (Cest) (ρ= 0,786 e P=0,021). Os resultados deste estudo mostram que a análise da mecânica respiratória pode ser realizada diariamente nestas crianças e ser utilizada com frequência, pois possibilita informações importantes do funcionamento pulmonar e esta análise pode ser feita em modo assistido controlado, sem a necessidade de sedar a criança. A estrutura física se correlacionou com a funcionalidade do pulmão. Apesar de nem todos os parâmetros terem sido correlacionados significativamente, existe correlação entre a estrutura do pulmão com sua função. / The analysis of respiratory mechanics allows to check lung function and changes for complication or injury of the lung. The analysis of arterial blood gases is important for adjustments in ventilatory parameters, enabling to check complications related to ventilation. The main objective of this study is to associate physical and functional parameters of the lung in children aged 0 to 1 year old, under mechanical ventilation postoperative cardiac surgery through the analysis of ventilatory parameters, respiratory mechanics with conventional radiographic procedure. In total, 46 children were analyzed in this age, but only those who had respiratory pattern and representative radiographs of the atelectasis and pleural effusion were selected. From 30 selected children, 10 had atelectasis and 8 had pleural effusion (PE). The data were analyzed before and after the onset of pulmonary complication. The data of the children without complication was originally used to check the possibility of analysis of respiratory mechanics through controlled cycles and their relationship to the data of arterial blood gases. Data were collected through the respiratory mechanics monitor and graph Inter ® GMX and program Wintracer and analysis of lung area by radiography through AutoCAD ® 2012. The analysis of the controlled waves of the respiratory cycles in assisted controlled mode of the newborn showed that the potential of hydrogen ionic (pH) does not change relatively to the value expected normal. All parameters of respiratory mechanics showed alterations between states with and without pulmonary complication. Among the groups with atelectasis there was statistically significant reduction in parameters tidal volume (VT), lung area (LA) and partial pressure of arterial oxygen (PaO2) and increase in respiratory frequency (RF) and Time in invasive mechanical ventilation (IMV). For the PE group there was a significant decrease in LA and significant increase in time at IMV. The compliance values were below normal for age and the resistance above normal values in all groups. The results of the Spearman coefficient (ρ) showed statistical significance between the LA with the parameters for the pulmonary atelectasis group in Raw parameters (ρ = -0.648 and P = 0.043) and the group with PE in Cst ( ρ = 0.786 and P = 0.021). The results of this study have shown that the analysis of respiratory mechanics can be performed daily in these children and be used frequently. It allows important information of lung function and can be analyzed in assisted controlled mode without the need of sedating the child. The physical structure correlated with the functionality of the lung, although not all parameters have been well correlated. Also, there is a correlation between the structure of lung and its function.

CAPES / A análise da mecânica respiratória possibilita verificar o funcionamento pulmonar e as possíveis alterações por alguma complicação ou lesão do pulmão. A análise da gasometria arterial é importante nos ajustes dos parâmetros ventilatórios, possibilitando verificar complicações relacionadas à ventilação. O objetivo principal deste estudo é associar os parâmetros físicos e funcionais do pulmão de crianças de 0 a 1 ano sob ventilação mecânica invasiva no pós-operatório de cirurgia cardíaca através da análise dos parâmetros ventilatórios e da mecânica respiratória com o procedimento radiográfico convencional. No total, 46 crianças foram analisadas nesta faixa etária, porém somente aquelas que apresentaram padrão respiratório e radiografias representativas de atelectasia e derrame pleural foram selecionadas. Das 30 crianças selecionadas, 10 apresentam atelectasia e 8 derrame pleural (DP). Os dados analisados são de antes e após o surgimento da complicação pulmonar. Os dados das crianças que não apresentaram nenhuma complicação inicialmente foram utilizados para verificar a possibilidade da análise da mecânica respiratória através dos ciclos controlados e a sua relação com os dados da gasometria arterial. Foram coletados dados da mecânica respiratória através do monitor gráfico Inter® GMX e do programa Wintracer e a análise da área do pulmão pela radiografia através do AutoCad® 2012. A análise das ondas controladas do ciclo respiratório em modo assistido controlado dos recém-nascidos mostra que o pH não se altera, em relação ao valor esperado normal. Todos os parâmetros da mecânica respiratória apresentaram alteração entre os estados sem e com complicação pulmonar. Os grupos com atelectasia apresentou significância estatística para redução nos parâmetros de volume corrente (VC), área do pulmão (AP) e pressão parcial de oxigênio arterial (PaO2) e aumento em frequência respiratória (FR) e Tempo em ventilação mecânica invasiva (VMI). No grupo DP a redução foi significativa em AP e houve aumento significativo do Tempo em VMI. Os valores de complacência ficaram abaixo da normalidade para a idade e de resistência acima dos valores considerados normais em todos os grupos. Os resultados do coeficiente de Spearman (ρ) que apresentaram significância estatística entre a AP com os parâmetros pulmonares foram para o grupo com atelectasia no parâmetro de resistência das vias aéreas (RVA) (ρ= -0,648 e P=0,043) e para o grupo com DP no parâmetro complacência estática (Cest) (ρ= 0,786 e P=0,021). Os resultados deste estudo mostram que a análise da mecânica respiratória pode ser realizada diariamente nestas crianças e ser utilizada com frequência, pois possibilita informações importantes do funcionamento pulmonar e esta análise pode ser feita em modo assistido controlado, sem a necessidade de sedar a criança. A estrutura física se correlacionou com a funcionalidade do pulmão. Apesar de nem todos os parâmetros terem sido correlacionados significativamente, existe correlação entre a estrutura do pulmão com sua função. / The analysis of respiratory mechanics allows to check lung function and changes for complication or injury of the lung. The analysis of arterial blood gases is important for adjustments in ventilatory parameters, enabling to check complications related to ventilation. The main objective of this study is to associate physical and functional parameters of the lung in children aged 0 to 1 year old, under mechanical ventilation postoperative cardiac surgery through the analysis of ventilatory parameters, respiratory mechanics with conventional radiographic procedure. In total, 46 children were analyzed in this age, but only those who had respiratory pattern and representative radiographs of the atelectasis and pleural effusion were selected. From 30 selected children, 10 had atelectasis and 8 had pleural effusion (PE). The data were analyzed before and after the onset of pulmonary complication. The data of the children without complication was originally used to check the possibility of analysis of respiratory mechanics through controlled cycles and their relationship to the data of arterial blood gases. Data were collected through the respiratory mechanics monitor and graph Inter ® GMX and program Wintracer and analysis of lung area by radiography through AutoCAD ® 2012. The analysis of the controlled waves of the respiratory cycles in assisted controlled mode of the newborn showed that the potential of hydrogen ionic (pH) does not change relatively to the value expected normal. All parameters of respiratory mechanics showed alterations between states with and without pulmonary complication. Among the groups with atelectasis there was statistically significant reduction in parameters tidal volume (VT), lung area (LA) and partial pressure of arterial oxygen (PaO2) and increase in respiratory frequency (RF) and Time in invasive mechanical ventilation (IMV). For the PE group there was a significant decrease in LA and significant increase in time at IMV. The compliance values were below normal for age and the resistance above normal values in all groups. The results of the Spearman coefficient (ρ) showed statistical significance between the LA with the parameters for the pulmonary atelectasis group in Raw parameters (ρ = -0.648 and P = 0.043) and the group with PE in Cst ( ρ = 0.786 and P = 0.021). The results of this study have shown that the analysis of respiratory mechanics can be performed daily in these children and be used frequently. It allows important information of lung function and can be analyzed in assisted controlled mode without the need of sedating the child. The physical structure correlated with the functionality of the lung, although not all parameters have been well correlated. Also, there is a correlation between the structure of lung and its function.

Introdução: O tratamento para o derrame pleural maligno recidivado tem caráter paliativo, sendo a pleurodese o método mais utilizado. Contudo, nem todos os procedimentos são efetivos, em parte por um encarceramento do pulmão pela pleura visceral espessada que impede o contato entre os folhetos pleurais e subsequente pleurodese efetiva. A elastância pleural reflete o grau de encarceramento da pleura visceral, contudo sua correlação com a efetividade da pleurodese não é bem conhecido. Objetivo: Analisar a correlação entre a elastância pleural e a efetividade radiológica (quantificada por tomografia de tórax) da pleurodese realizada através de cateteres pleurais. Os objetivos secundários deste estudo são: correlacionar a elastância pleural com a qualidade de vida, graus de dispneia e dor após o procedimento, efetividade clínica, complicações e mortalidade. Correlacionar a posição da extremidade do cateter pleural com o sucesso radiológico e clínico da pleurodese. Métodos: Estudo prospectivo com 131 pacientes candidatos a pleurodese por instilação de nitrato de prata ou talco mineral por cateter pleural. As pressões pleurais foram aferidas através de manômetro hidrostático ou de transdutor eletrônico de pressão vascular durante o esvaziamento do líquido e usadas para calcular a elastância pleural, em cm H2O/L. A efetividade radiológica foi avaliada pelos volumes pleurais medidos por tomografias computadorizadas de tórax logo após a drenagem e 30 dias após a pleurodese. A efetividade clínica foi avaliada conforme a necessidade de procedimentos adicionais para controle de sintomas. A qualidade de vida foi avaliada através do questionário geral da OMS. A avaliação da dor foi feita pela quantificação na Escala Visual Analógica de Dor. A análise da dispneia foi realizada através da quantificação da funcionalidade na escala de dispneia do British Medical Research Council. Todos esses questionários foram aplicados antes da drenagem, 30 dias após pleurodese e, então, trimestralmente. Para a análise da segurança dos procedimentos foram considerados os tempos de internação e de drenagem e a ocorrência de complicações. Todos os pacientes foram seguidos até o óbito ou até o término do estudo, em novembro de 2014, registrando as complicações e as datas do óbito para a construção da curva de sobrevida. Resultados: Avaliamos 87 pacientes de um total de 131 recrutados. Não houve diferença entre os volumes pleurais nas duas tomografias realizadas. A efetividade clínica foi observada em 86,20% dos pacientes. Não houve diferença em nenhum dos domínios da qualidade de vida. Encontramos diferenças entre a dispneia e a dor aferidas 30 dias após a pleurodese e antes da drenagem. Complicações ocorreram em 14,94% dos casos. A mediana da sobrevida global foi de 16 meses. Não foram encontradas correlações entre as elastâncias pleurais em 400 ml, 800 ml e total com nenhum dos desfechos radiológicos, clínicos (efetividade clínica, qualidade de vida, dispneia, dor e complicações) ou com a sobrevida dos pacientes. A posição da ponta do cateter pleural não se correlacionou com o sucesso radiológico ou clínico da pleurodese. Conclusões: A elastância pleural não se mostrou, até o presente momento, capaz de predizer os defechos radiológicos, clínicos e a sobrevida em pacientes submetidos a pleurodese / Background: The treatment of recurrent malignant pleural effusion has a palliative purpose. Pleurodesis is the most used method. However, not all the procedures are effective, in part because of the lung entrapment by the visceral pleura, preventing the contact between the pleural surfaces and subsequente effective pleurodesis. The pleural elastance reflects the degree of entrapment of the visceral pleura, but its correlation with the effectiveness of pleurodesis is not well known. Objetive: To evaluate the correlation between pleural elastance and radiological effectiveness (measured by tomography) of bedside pleurodesis. The secondary objectives of this study are: correlating the pleural elastance with quality of life, degree of dyspnea and pain after the procedure, clinical effectiveness, complications and mortality. Evaluate the role of intrapleural position of the pleural catheter in early lung expansion and success of pleurodesis. Methods: Prospective study including 131 patients with recurrent malignant pleural effusion candidates for treatment with bedside pleurodesis with silver nitrate or mineral talc. Pleural pressures were measured through hydrostatic gauge or electronic pressure transducer during emptying of effusion and used to calculate the pleural elastance in cm H2O/L. Pleural volumes measured by CT scans of the chest after drainage and 30 days after pleurodesis were assess the radiological effectiveness. The clinical effectiveness was evaluated as the need for additional procedures to control symptoms. The quality of life was assessed using the WHO general questionnaire. Quantifying the Visual Analog Scale of Pain did pain assessment. Measuring the functionality in the British Medical Research Council dyspnea scale made the analysis of dyspnea. All these questionnaires were applied prior to drainage, 30 days after pleurodesis and then quarterly. Results: We evaluated 87 patients of a total of 131 recruited. There was no difference between the two pleural volumes CT scans performed. The clinical effectiveness was observed in 86.20% of patients. There was no difference in any of the domains of quality of life. We found differences between dyspnea and pain measured 30 days after pleurodesis and before draining. Complications occurred in 14.94% of cases. The median overall survival was 16 months. No correlations between pleural elastance in 400 ml, 800 ml and complete were found with all the imaging, clinical (clinical effectiveness, quality of life, dyspnea, pain and complications) or with patient survival outcomes. The tip of the pleural catheter was not correlated with the radiological or clinical success of pleurodesis. Conclusions: The pleural elastance was not, so far, able to predict the radiological outcomes, clinical outcomes and survival in patients undergoing bedside pleurodesis

OBJETIVO: O objetivo deste estudo foi predizer o prognóstico perinatal em fetos com derrame pleural isolado por meio da medida do volume pulmonar estimado pela ultrassonografia tridimensional. MÉTODO: Estudo retrospectivo, entre julho de 2005 e julho de 2010, com 19 fetos com derrame pleural isolado (ausência de causas infecciosas, imunes, anomalias cromossômicas ou estruturais associadas) acompanhados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Os volumes pulmonares foram obtidos pela ultrassonografia tridimensional (Voluson 730 Expert, GE Medical System, Kretzechnick, Áustria) em dois períodos, no momento do diagnóstico (20 26 semanas) e próximo ao parto (duas semanas antecedentes ao parto ou até 36 semanas), e mensurados pela técnica VOCAL (Virtual Organ Computer Aided Analysis) com rotação de 30º. Os volumes obtidos (observados) foram comparados com valores esperados para idade gestacional, e a razão entre o volume total fetal observado/esperado (VPTo/e) foi avaliada de acordo com a mortalidade perinatal e morbidade neonatal (necessidade de ventilação mecânica por mais que 48 horas). RESULTADOS: Dezenove fetos com derrame pleural isolado foram analisados no período do estudo. Doze (63,2%) crianças sobreviveram. Dos sobreviventes, sete (58,3%) apresentaram morbidade respiratória. O VPTo/e no primeiro exame ultrassonográfico não se associou significativamente com mortalidade (VPTo/e: 0,42±0,19 nos sobreviventes contra 0,30±0,08 nos não sobreviventes, p=0,11). No segundo exame, por outro lado, VPTo/e foi significativamente menor nos casos que faleceram (0,24±0,08) em relação aos sobrevivente (0,58±0,21; p<0,01) e nos que necessitaram de ventilação mecânica prolongada (0,35±0,08) comparados aos que não necessitaram (0,68±0,10; p<0.01). CONCLUSÃO: O volume pulmonar fetal medido pela ultrassonografia tridimensional pode ser utilizado para predizer o prognóstico de fetos com derrame pleural isolado. / OBJECTIVE The aim of the present study was to predict the perinatal outcome in isolated pleural effusion using fetal lung volumes assessed by three-dimensional ultrasonography. METHODS: A retrospective study conducted between July 2005 and July 2010, in which 19 fetuses with isolated pleural effusion (absence of infection, immunological causes, chromosomal anomalies and associated structural anomalies) at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Fetal lung volumes were assessed by three-dimensional ultrasonography (Voluson 730 Expert, GE Medical System, Kretzechnick, Áustria) in two periods: at diagnosis (20-26 weeks) and nears the delivery (2 weeks before delivery or at 36 weeks), by VOCAL technique (Virtual Organ Computer Aided Analysis) with rotation of 30o. The observed volumes were compared to expected values for determine gestational age, and the observed/expected total fetal lung volume ratio (o/e-TFLV) was evaluated according to perinatal death and neonatal morbidity (need for mechanical ventilation longer than 48 hours). RESULTS: A total of 19 fetuses with isolated pleural effusion were evaluated during the study period. Twelve (63.2%) infants survived. Among the survivors, seven (58.3%) had severe respiratory distress at birth. The o/e-TFLV at the first ultrasound examination was not associated statistically with mortality (o/e-TLFV: 0.42±0.19 in survivors x 0.30±0.08 among those that died, p=0.11). On the second ultrasound examination, on the other hand, the o/e-TFLV was significantly reduced in those cases that died (0.24±0.08) whilst in survivors (0.58±0.21; p<0.01) and in those that needed mechanical ventilation (0.35±0.08) when compared to those that did not need it (0.68±0.10; p<0.01). CONCLUSION: Fetal lung volumes measured by three-dimensional ultrasonography may be useful to predict perinatal outcome in fetuses with primary pleural effusion

Thesis (MScEng)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Pleural effusion is a common respiratory condition that is characterized by an abnormal collection of fluid in the lung cavity. In this study, an innovation using the transmission of sound into the respiratory system as a novel tool to detect fluid in the lung was developed. First, the method was evaluated on a phantom model of a lung. Based on the results of this test model, the appropriate technique was used in a clinical study. This method has several advantages, such as that is non-invasive, low cost, and easy for clinical review. Two techniques, including analysis of the frequency response of the model and the transient time of transmitted sound in the lung, were evaluated in the phantom models of the human lung. Two phantom models with similar geometry to the human lung, including a healthy model (without fluid in the model) and a pleural effusion model (with bulk of fluid in the model) were developed. These models have acoustical properties similar to the lung parenchyma. To obtain the frequency responses of the model, a sine sweep signal was transmitted into the model and the frequency response of the model was then calculated using the fast Fourier transform. The transient time of the transmitted sound was calculated using a cross correlation method. The results show that the locations of fluid in the model were detectable using both techniques. However, the transient time technique is better than the frequency response technique because it is simple, fast, and has potential for use in a clinical enviorment. Based on the results obtained from the phantoms, the transient time method was performed on both 22 healthy participants and four patients diagnosed with pleural effusion. To perform this technique on human subjects, a data acquisition system was developed. Two types of sound, including a complex chirp sound and a polyphonic sound, were transmitted into the respiratory systems of the participants. The time delay between a reference microphone, located on the trachea of the subject, and eight microphones attached to the chest was computed using a cross correlation method, and the effect of inhalation and lung size on the transient time of transmitted sound on the healthy subject was evaluated. The results show that using transmission of sound in the lung is a promising technique in the diagnosis of pleural effusion. / AFRIKAANSE OPSOMMING: Pleurale effusie is 'n algemene respiratoriese toestand wat gekenmerk word deur 'n abnormale versameling van vloeistof in die longholte. In hierdie studie is 'n innoverende manier ontwikkel om vloeistof in die long met behulp van die transmissie van klank te bespeur. Die metode is eers op 'n fantoommodel van 'n long geëvalueer. Op grond van die resultate van hierdie toetsmodel is die geskikte tegniek in 'n kliniese studie gebruik. Hierdie metode het verskeie voordele, soos dat dit ingreepsvry is, nie duur is nie en kliniese evaluering moontlik maak. Twee tegnieke, naamlik ontleding van die frekwensierespons van die model en die oorgangstyd van versende klank in die long, is in die fantoommodel van die menselong geëvalueer. Twee fantoommodelle met soortgelyke geometrie aan die menselong, met inbegrip van 'n gesonde model (sonder vloeistof in die model) en 'n pleurale-effusie-model (met 'n massa vloeistof in die model), is ontwikkel. Hierdie modelle het akoestiese eienskappe soortgelyk aan die longparenchiem. Om die frekwensieresponse van die model te verkry, is 'n sinuskrommesein tot in die model versend. Die frekwensierespons van die model is met behulp van die vinnige Fourier-transformasie bereken. Die oorgangstyd van die versende klank is deur 'n kruiskorrelasie-metode bereken. Die resultate toon dat die ligging van die vloeistof in die model met albei tegnieke bespeur kan word. Die oorgangstyd-tegniek is egter beter as die frekwensierespons-tegniek, aangesien dit eenvoudig en vinnig is en maklik in 'n kliniese omgewing gebruik kan word. Op grond van die resultate wat van die fantome verkry is, is die oorgangstyd-metode op 22 gesonde deelnemers en vier pasiënte wat met pleurale effusie gediagnoseer is, uitgevoer. 'n Dataverkrygingstelsel is ontwikkel ten einde hierdie tegniek op proefpersone uit te voer. Twee soorte klank, naamlik 'n komplekse tjirpgeluid en 'n polifoniese klank, is na die respiratoriese stelsels van die deelnemers versend. Die tydvertraging tussen 'n verwysingsmikrofoon in die tragea van die proefpersoon en agt mikrofone wat aan die bors vasgeheg is, is met 'n kruiskorrelasie-metode bereken, en die uitwerking van inaseming en longgrootte op die oorgangstyd van versende klank op die gesonde proefpersone is geëvalueer. Die resultate toon dat die gebruik van transmissie van klank in die long 'n belowende tegniek vir die diagnose van pleurale effusie is.

Thesis (PhD)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Although transthoracic ultrasonography is a well established modality, it is still underutilised by chest physicians. The aim of this research project was to investigate the feasibility, diagnostic yield and safety of ultrasound(US)-assisted transthoracic biopsies performed by clinicians in various settings relevant to daily practice of respiratory medicine. We conducted four clinical trials which are summarised below: 1. In a prospective study on the feasibility of US-assisted transthoracic fine needle aspiration (TTFNA) of drowned lung secondary to a proximal mass lesion, a novel indication for US-assisted TTFNA was described. TTFNA passes >20mm from the visceral pleura had a sensitivity of 74.2% and were also more likely to contain malignant cells than more superficial passes. The surprisingly high yield and the fact that no serious complications were observed validated this approach, which may be an alternative to bronchoscopy. 2. In the largest single-centre study on US-assisted TTFNA with rapid on-site evaluation (ROSE) and cutting needle biopsy (CNB) in the setting of superior vena cava (SVC) syndrome ever reported, we were able to accurately diagnose 96% of all patients who presented with an associated mass lesion that abutted or infiltrated the chest wall. No pneumothoraces or major haemorrhage was caused. We also validated the single-session approach, and were able to conclude that US-assisted TTFNA (with ROSE) is the initial investigation of choice in suspected bronchogenic carcinoma, whereas both TTFNA and CNB need to be performed in all other cases. 3. We continued to validate the novel single-session sequential approach in a study on anterosuperior mediastinal masses. US-assisted TTFNA with ROSE was performed on 45 consecutive patients, immediately followed by CNB where a provisional diagnosis of epithelial carcinoma or probable tuberculosis (TB) could not be established. An accurate cytological diagnosis was made in 73.3%, and was more likely to be diagnostic in epithelial carcinoma and TB than all other pathology (p<0.001). CNB yielded a diagnosis in 88.2%. Overall 93.3% of patients were diagnosed by the single-session approach. No pneumothorax or major haemorrhage was observed. 4. In a prospective study, we compared US-assisted Abrams and Tru-Cut needle biopsies with regard to their yield for pleural TB. Pleural biopsy specimens obtained with Abrams needles contained pleural tissue in 91.0% of cases and were diagnostic in 81.8%, whereas Tru-Cut needle biopsy specimens only contained pleural tissue in 78.7% (p=0.015) and were diagnostic in 65.2% (p=0.022). In conclusion, we investigated the feasibility of US-assisted biopsies performed by respiratory physicians in various settings, and consistently found acceptable to very high diagnostic yields with minimal complications. Furthermore, we were able to validate a novel indication for US-assisted TTFNA (US-assisted TTFNA of drowned lung), validate the use of a single-session sequential approach (USassisted TTFNA with ROSE followed by CNB where indicated) in at least two clinical settings (SVC syndrome and anterosuperior mediastinal masses) and we were able to show that US-assisted Abrams needle biopsy is superior to Tru-Cut needles biopsy when histological confirmation of TB pleuritis is required. / AFRIKAANSE OPSOMMING: Alhoewel transtorakale ultrasonografie ‘n gevestigde modaliteit is, word dit onderbenut deur pulmonoloë. Die doel van hierdie navorsingsprojek was om die praktiese uitvoerbaarheid, diagnostiese opbrengs en veiligheid van sonargerigte transtorakale biopsies uitgevoer deur klinici in verskeie situasies relevant tot die alledaagse praktyk te ontleed. Ons het vier kliniese proewe uitgevoer wat hieronder opgesom word: 1. In ‘n prospektiewe studie oor die praktiese uitvoerbaarheid van sonargerigte transtorakale fyn naald aspirasie (TTFNA) van areas van obstruktiewe pneumonitis sekondêr tot proksimale massa letsels, is ‘n nuwe indikasie vir sonargerigte TTFNA beskryf. TTFNA aspirasies wat >20mm van die visserale pleura geneem is, het ‘n sensitiwiteit van 74.2% gehad en was meer geneig om maligne selle op te lewer as meer oppervlakkige aspirasies. Die verbasende hoë diagnostiese sensitiwiteit en afwesigheid van ernstige komplikasies het die praktiese waarde van hierdie benadering bevestig. 2. In die grootste studie nog oor sonargerigte TTFNA met spoedige in-teater evalusies (SITE) en sny-naald biopsie (SNB) in die teenwoordigheid van superior vena cava (SVC) sindroom, kon ons 96% van pasiënte wat presenteer het met ‘n geassosieerde massa letsel wat die borskaswand betrek, akkuraat diagnoseer. Geen pneumotoraks of major bloeding is waargeneem nie. Ons kon ook die praktiese uitvoerbaarheid van ‘n enkelsessie benadering bevestig en kon tot die gevolgtrekking kom dat sonargerigte TTFNA (met SITE) die aanvanklike ondersoek van keuse is waar bronguskarsinoom vermoed word, maar dat beide TTFNA en SNB noodsaaklik is in ander gevalle. 3. Ons het voortgegaan om die waarde van die nuwe enkel-sessie benadering te bevestig in ‘n studie oor antero-superior mediastinale massas. Sonargerigte TTFNA met SITE is uitgevoer op 45 pasiënte en in gevalle waar ‘n voorlopige diagnose van epiteliale karsinoom of waarskynlike tuberkulose (TB) nie bevestig kon word nie, is dit onmiddelik gevolg deur SNB. ‘n Akkurate sitologiese diagnose is gemaak in 73.3% van gevalle en meer algemeen in epiteliale karsinoom en TB as ander patologie (p<001). SNB was diagnosties in 88.2%. In 93.3% kon ‘n diagnose verkry word met die enkel-sessie benadering. Geen pneumotoraks of major bloeding is waargeneem nie. 4. In ‘n prospektiewe studie is sonargerigte Abrams naald en Tru-Cut naald biopsies se opbrengs vir pleurale TB met mekaar vergelyk. Pleurale biopsie monsters wat met ‘n Abrams naalde geneem is, het pleurale weefsel in 91.0% gevalle getoon en was diagnosties in 81.8%, vergeleke met Tru-Cut naalde wat slegs in 87.7% pleurale weefsel opgelewer het (p=0.015) en wat net in in 65.2% diagnosties was (p=0.022). Opsommend het ons die praktiese uitvoerbaarheid van sonargerigte biopsies uitgevoer deur pulmonoloë in veskeie kliniese situasies nagevors, en het deurlopend aanvaarbare tot hoë diagnostiese opbrengste gevind met minimale komplikasies. Verder kon ons ‘n nuwe indikasie vir sonargerigte TTFNA beskryf en evalueer (sonargerigte TTFNA van obstruktiewe pneumonitis); ‘n enkel-sessie sekwensiële benadering se waarde bevestig (sonargerigte TTFNA met SITE, gevolg deur SNB waar aangedui) in ten minste twee kliniese situasies (SVC sindroom en anterosuperior mediastinale massas); en was dit moontlik om te bewys dat UK-geleide Abrams naald biopsies superior tot Tru-cut naald biopsies is in die histologiese bevestiging van TB pleuritis.

Os métodos convencionais para o diagnóstico da tuberculose (TB) pleural possuem várias limitações, assim métodos mais sensíveis e específicos são necessários. O objetivo deste estudo foi avaliar uma metodologia de hibridização em microplaca e uma técnica de reação em cadeia da polimerase (PCR) em tempo real para a detecção de DNA de Mycobacterium tuberculosis em amostras de líquido pleural, fragmento de pleura e soro. Adicionalmente, foi avaliada a utilidade da PCR em tempo real em paralelo com a cultura do líquido pleural para o diagnóstico de TB pleural. Foram avaliados 161 pacientes com derrame pleural e submetidos à toracocentese e biópsia pleural. O padrão-ouro para definição de um caso de TB pleural baseou-se na combinação de baciloscopia, cultura, exame histopatológico e critérios clínicos. Cento e sete dos 161 pacientes com derrame pleural receberam diagnóstico de TB pleural. Os resultados da metodologia de hibridização em microplaca não foram satisfatórios, assim foi desenvolvida uma técnica de PCR em tempo real. Nas amostras de líquido pleural, a PCR em tempo real mostrou uma sensibilidade de 46% (IC 95%, 36%-56%) com especificidade de 100%, enquanto a cultura obteve uma sensibilidade de 29% (IC 95%, 20%- 38%). A PCR em tempo real realizada em associação com a cultura no líquido pleural apresentou uma sensibilidade de 60% (IC 95%, 50%-70%). Para as amostras de fragmento pleural, a PCR em tempo real mostrou uma sensibilidade de 42% (IC 95%, 26%-59%) e especificidade de 100%, para este tipo de amostra o exame histopatológico apresentou a maior sensibilidade (90% - IC 95%, 84%- 96%). Nas amostras de soro a PCR em tempo real foi positiva em apenas dois pacientes, os quais também apresentaram resultado positivo nos outros tipos de amostras. Estes resultados indicam que a PCR em tempo real realizada no líquido pleural pode ser uma forma útil para obter um diagnóstico de TB pleural mais rápido, específico e com um procedimento menos invasivo para coleta das amostras. / Conventional tests for pleural tuberculosis (TB) have several limitations and more sensitive and specific methods are needed. The aim of this study was to evaluate microwell hybridization and real-time PCR (polimerase chain reaction) for detection of Mycobacterium tuberculosis DNA in pleural fluid, pleural tissue and serum. Additionally, the utility of real-time PCR in parallel with culture in pleural fluid for the diagnosis of pleural TB was assessed. One hundred sixty one patients with a pleural effusion submitted to a thoracentesis and pleural biopsy were evaluated. The gold-standard for case definition of pleural TB were the combination of acid-fast bacilli, culture, histopathologic examination and clinical parameters. One hundred seven of the 161 patients with pleural effusion received diagnosis of pleural TB. Results of microwell hybridization were not satisfactory, thus we developed a real-time PCR assay. In pleural fluid specimens, real-time PCR showed a sensitivity of 46% (CI 95%, 36%-56%) with specificity of 100%, while the sensitivity of culture was 29% (CI 95%, 20%-38%). The combination of real time PCR and culture in pleural fluid showed a sensitivity of 60% (CI 95%, 50%-70%). For the pleural tissue, real-time PCR showed a sensitivity of 42% (CI 95%, 26%-59%) with specificity of 100%, for this specimen histopathologic examination had the highest sensitivity (90% - CI 95%, 84%-96%). In the serum real-time PCR was positive in only two patients, which also had positive results in other specimens. Our results indicate that the real-time PCR is a useful approach to achieve a more rapid and specific diagnosis for pleural TB with a less invasive procedure for specimen collection.

Thèse d'exercice : Médecine. Médecine générale : Paris 12 : 2004. / Titre provenant de l'écran-titre. Bibliogr.

Η κακοήθης υπεζωκοτική συλλογή (ΚΥΣ), προκαλούμενη από μεταστατικά αδενοκαρκινώματα είτε από πρωτοπαθή μεσοθηλιώματα, αποτελεί μείζον κλινικό πρόβλημα καθώς σηματοδοτεί συστηματική νεοπλασματική διασπορά και χαμηλό προσδόκιμο επιβίωσης. Η τρέχουσα αντιμετώπισή της είναι μη αιτιολογική και συχνά αναποτελεσματική. Ενώ τα νεοπλάσματα που προκαλούν ΚΥΣ φέρουν καλά χαρακτηρισμένες μεταλλάξεις και ο υπεζωκότας θεωρείται προνομιακή ανατομική θέση γονιδιακής θεραπείας, οι μέχρι τώρα μελέτες της αποτελεσματικότητας της υπεζωκοτικής διαγονιδιακής μεταφοράς υπήρξαν αποσπασματικές. ΣΚΟΠΟΣ: Σκοπός της παρούσας μελέτης είναι ο χαρακτηρισμός της έκτασης, της αποτελεσματικότητας και της λειτουργικότητας της διαγονιδιακής μεταφοράς τόσο στο φυσιολογικό υπεζωκοτικό μεσοθήλιο, όσο και και στον πάσχοντα υπεζωκότα με πρωτοπαθείς ή μεταστατικούς όγκους. ΥΛΙΚΑ ΚΑΙ ΜΕΘΟΔΟΙ: Υγιείς ποντικοί φυσικού τύπου C57BL/6 και διαγονιδιακοί ποντικοί-ιχνηλάτες mT.mG έλαβαν ενδοϋπεζωκοτικές εγχύσεις 5 x 108 μολυσματικών μονάδων αδενοϊών τύπου 5 (Ad) που κωδικοποιούν τα γονίδια της λουσιφεράσης (Luc), της πράσινης φθορίζουσας πρωτεΐνης (GFP) και της Cre ρεκομπινάσης. Η αποτελεσματικότητα της διαγονιδιακής μεταφοράς μελετήθηκε με απεικόνιση βιοφωταύγειας/βιοφθορισμού, καθώς και με φθορίζουσα μικροσκοπία. Τα πειράματα επαναλήφθηκαν σε ποντικούς με ΚΥΣ, οι οποίες προκλήθηκαν μέσω υπεζωκοτικής έγχυσης 150.000 κυττάρων συγγενικού μεσοθηλιώματος υπεζωκότα (ΑΕ17) και αδενοκαρκινώματος πνεύμονα (LLC). Προκειμένου να μελετηθεί αν οι αδενοϊοί σε ποιο βαθμό μπορούν να διαμολύνουν κύτταρα in vitro , ανθρώπινες και ποντικίσιες κυτταρικές σειρές , φυσιολογικές και καρκινικές , διαμολύνθηκαν με 10ng/μl Ad-luc και Ad-GFP. AΠΟΤΕΛΕΣΜΑΤΑ: Η θωρακική φωτεινή εκπομπή ποντικών C57BL/6 κορυφώθηκε την πρώτη και υποχώρησε τη δεύτερη εβδομάδα μετά ενδοϋπεζωκοτική έγχυση Ad-Luc . Δύο εβδομάδες μετά από ενδοϋπεζωκοτική χορήγηση Ad-Cre σε ποντικούς mT.mG παρατηρήθηκε διάχυτη εξάλειψη του ερυθρού και εμφάνιση πράσινου φθορίζοντος σήματος σε όλες τις υπεζωκοτικές επιφάνειες, το οποίο εντοπιζόταν κατ’ αποκλειστικότητα στο μεσοθήλιο. Δύο εβδομάδες μετά από έγχυση Ad-Cre σε ποντικούς mT.mG που είχαν αναπτύξει όγκους παρατηρήθηκε πράσινος φθορισμός μαζί με τον κόκκκινο μέσα στους όγκους. Στατιστικώς σημαντική διαμόλυνση παρατηρήθηκε in vitro στα κύτταρα φυσιολογικού μεσοθηλίου, μεσοθηλιώματος ανθρώπου και ποντικού , αδενοκαρκινώματος πνεύμονα και παγκρέατος ποντικού. ΣΥΜΠΕΡΑΣΜΑΤΑ: Η ενδοϋπεζωκοτική έγχυση ανασυνδυασμένων αδενοιών αποτελεί αποτελεσματική μέθοδο διαγονιδιακής μεταφοράς στο φυσιολογικό και παθολογικό υπεζωκοτικό μεσοθήλιο. Ο βαθμός της διαγονιδιακής μεταφοράς επιβεβαιώνεται με τη διαμόλυνση φυσιολογικών και καρκινικών κυτταρικών σειρών in vitro. / --

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