Chest
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Thoracoscopy is an excellent means for staging esophageal cancer. Staging of esophageal carcinoma facilitates prognostication and allocation of patients to appropriate treatment regimens. ⋯ Routine thoracoscopic and laparoscopic lymph node staging has been used in patients with esophageal carcinoma with excellent results. Thoracoscopy can allocate patients for neoadjuvant therapy and help avoid an unnecessary thoracotomy in patients found to have gross spread of locoregional disease.
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Patients with ARDS typically have functionally small lungs. A growing body of clinical and experimental evidence has demonstrated that mechanical ventilation that results in high transpulmonary pressure gradients and overdistention of lung units will potentiate the acute lung injury in patients with ARDS. ⋯ The goal of this article is to provide a simple and practical approach to the management of PCV in patients with ARDS. Implicit in our approach is the use of a ventilator with PCV software and waveform capabilities.
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Multicenter Study Clinical Trial
Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes.
The purpose of this investigation is to determine the characteristics of the history, physical examination, chest radiograph, and ECG, and the ventilation/perfusion (V/Q) lung scan probability in patients with pulmonary embolism (PE) stratified according to their presenting syndrome. ⋯ Many of the findings in the various syndromes of PE can be understood in terms of the severity of PE as it increases from mild with the pulmonary infarction syndrome to moderate with the isolated dyspnea syndrome to severe with circulatory collapse. The prevalence of various clinical and laboratory characteristics of patients with the syndrome of pulmonary infarction, isolated dyspnea, or circulatory collapse may give clues to the diagnosis or suggest characteristics that may reduce the likelihood of inadvertently discarding the diagnosis of PE.
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Lung volume reduction surgery (LVRS) has shown promise for treating patients with severe emphysema in recent clinical trials. However, response following surgery is difficult to assess due to frequent discrepancies between subjective and objective outcomes. We evaluated the relationship between improvement in dyspnea and pulmonary function response in 145 consecutive patients with inhomogeneous emphysema enrolled in a bilateral thoracoscopic lung volume reduction protocol in order to assess predictors of improved dyspnea outcome and correlation of subjective and objective improvement measures. ⋯ Bilateral thoracoscopic staple LVRS results in significant objective and subjective improvement in patients with severe emphysema and hyperinflation. There was considerable variability between improvement in dyspnea and improvement in spirometry, and preoperative predictors of response may differ between these outcome variables. Further studies are needed to define the long-term implications of these findings.
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Preoperative evaluation of patients being considered for pulmonary resection is a common practice for both pulmonologists and internists. Traditionally, preoperative evaluation of this population has entailed identifying patients in whom pulmonary resection carries an unacceptably high risk of morbidity and mortality. However, recent advances in surgical technique and patient management have prompted a reconsideration of traditional preoperative approaches. This article reviews procedures currently used in the preoperative evaluation of patients considered for pulmonary resection, including the patient history, physical examination, and preoperative interventions, and addresses further evaluation of the high-risk patient.