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Study Objectives: To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety.Design: Randomized controlled trial.Setting: Teaching hospital in Baltimore, MD.Patients: Consecutive adult patients (n = 80) undergoing FB with conscious sedation.Intervention: Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds.Measurements and Results: The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96).Conclusions: Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures. [ABSTRACT FROM AUTHOR]

Background: Prior to the 1980s, permanent feeding tube placement was limited to an open surgical procedure until Gauderer and colleagues described the safe placement of percutaneous endoscopic gastrostomy (PEG) tubes. This procedure has since expanded beyond the realm of surgeons to include gastroenterologists, thoracic surgeons, and interventional radiologists. In some academic centers, interventional pulmonologists (IPs) also perform this procedure. We describe the safety and feasibility of PEG tube placement by IPs in a critically ill population., Methods: Prospectively collected data of patients in a medical ICU undergoing PEG tube placement from 2003 to 2007 at a tertiary-care center were reviewed. Inclusion criteria included all PEG tube insertions performed or attempted by the IP team. Data were collected on mortality, PEG tube removal rate, total number of days with PEG tube, and complication rates. Follow-up included hospital length of stay and phone contact after discharge. Procedural and long-term PEG-related complications were recorded., Results: Seventy-two patients were studied. PEG tube insertion was completed successfully in 70 (97.2%), with follow-up data in 69 of these 70. Thirty-day mortality was 11.7%. No deaths or immediate complications were attributed to PEG tube placement. PEG tube removal occurred in 27 patients, with a median time to removal of 76 days., Conclusions: Bedside PEG tube placement can be performed safely and effectively by trained IPs. Because percutaneous tracheostomy is currently performed by IPs, the ability to place both PEG and tracheostomy tubes at the same time has the potential for decreased costs, anesthesia exposure, procedural times, ventilator times, and ICU days.

Background: Cough is a pervasive and disabling symptom of idiopathic pulmonary fibrosis (IPF) and is an independent predictor of disease progression. The Cough Quality-of-Life Questionnaire (CQLQ) is a validated measure of cough-specific quality of life that could be used as an outcome measure in therapeutic trials for IPF. This study aimed to assess the reliability and validity of the CQLQ in individuals with IPF., Methods: The CQLQ was administered as an outcome within a previously published 27-week, placebo-controlled, crossover trial of thalidomide for cough in IPF. Participants were adults with IPF and chronic cough. A cough visual analog scale (VAS) and the St. George's Respiratory Questionnaire (SGRQ) were administered to establish concurrent validity of the CQLQ., Results: Internal consistency was high (Cronbach α > .70) for the CQLQ total and four of six subscale scores. The CQLQ total score demonstrated concurrent validity through significant correlations with scores on the cough VAS and SGRQ total and subscale scores (r range, 0.63-0.81; P < .05). The intraclass correlation coefficient for the CQLQ completed at baseline and after a therapeutic washout period at week 15 was 0.87, indicating very good test-retest reliability., Conclusions: This study supports the use of the CQLQ as a valid and reliable instrument in IPF and should be used to assess cough-specific quality of life in therapeutic trials.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit., Methods: We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge., Results: A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001)., Conclusions: There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Background: As the cystic fibrosis (CF) population has aged, many chronic health problems have emerged, including diabetes mellitus and osteoporosis. Previous studies have suggested that pain is common in patients with CF; however, little is known about the factors associated with it or its impact on clinical outcomes. We hypothesized that pain is common, is associated with psychologic distress, and adversely affects clinical outcomes., Methods: From February 1, 2008, to April 3, 2008, adults with CF from Johns Hopkins Hospital were surveyed about their pain. Outcomes were assessed for 12 months following survey completion. Bivariate analyses were performed using Wilcoxon log rank, Kruskal-Wallis tests, and Spearman correlations. Logistic regression models and Cox proportional hazard models were used to analyze clinical outcomes., Results: Eighty-three patients (61%) completed the survey. Eighty-two percent of patients reported pain within the past month, the most common sites being the head, sinuses, back, and chest. Pain frequently interfered with general activities (41.9%), mood (56.8%), and work (47.3%). Symptoms of depression and anxiety, as well as lower quality-of-life (QOL) scores, were associated with the presence of pain (P < .05 for each). The risk of pulmonary exacerbations was increased in patients with higher levels of pain, even after adjusting for FEV(1) and age (OR = 1.65; P = .038; 95% CI, 1.03-2.64). Additionally, the risk of death was higher in patients with higher average pain scores (HR = 2.28; P = .008; 95% CI = 1.2-4.2)., Conclusions: Pain is common in adults with CF, interferes with activities, and is associated with lower QOL and an increased risk of both exacerbations and death.

Background: Vitamin D deficiency is common in patients with cystic fibrosis (CF), and guidelines recommend 25-hydroxyvitamin D (25OHD) levels ≥ 30 ng/mL. This threshold was selected because serum parathyroid hormone (PTH) rises in healthy individuals when the 25OHD level falls below 30 ng/mL. PTH levels > 50 pg/mL are associated with an increased risk of bone loss. However, the relationship between 25OHD and PTH has not been studied in CF. We sought to determine the appropriate goal 25OHD level in patients with CF by identifying the level below which the risk of PTH > 50 pg/mL begins to increase., Methods: Levels of 25OHD and PTH in 216 individuals with CF were collected prospectively. Individuals with 25OHD < 30 ng/mL were treated with vitamin D2, and levels were reevaluated., Results: Mean 25OHD level was 25.7 ± 12.4 ng/mL, and mean PTH level was 46.7 ± 25.9 pg/mL. In 63% of individuals, 25OHD level was < 30 ng/mL, and in 38.0% it was ≤ 20 ng/mL. Low 25OHD levels were significantly associated with elevated PTH levels, with a mean PTH of 53.1 ± 29.8 pg/mL for 25OHD level 0 to 19 ng/mL; 51.1 ± 30.7 pg/mL for 25OHD level 20 to 29 ng/mL; 38.4 ± 16.4 pg/mL for 25OHD level 30 to 39 ng/mL; and 37.2 ± 16.4 pg/mL for 25OHD level ≥ 40 ng/mL (P = .006). We assessed the sensitivity of different 25OHD thresholds to identify individuals meeting the goal of a PTH level < 50 pg/mL to reduce the risk of bone loss. To obtain 90% sensitivity, a 25OHD level ≥ 35 ng/mL was required. Strikingly, 23% of individuals with 25OHD levels 30 to 34 ng/mL still had a PTH level > 50 pg/mL. This decreased to 14% for 25OHD level ≥ 35 ng/mL., Conclusions: Inadequate serum 25OHD levels are common in adults with CF and are associated with elevated PTH levels. Aiming to maintain 25-OHD levels ≥ 35 ng/mL in individuals with CF decreases the risk of having a PTH level associated with secondary hyperparathyroidism and bone loss.

Background: Infection with multiple antibiotic-resistant Pseudomonas aeruginosa (MARPA) in individuals with cystic fibrosis (CF) has caused much concern among caregivers, yet little is known about the risks associated with acquiring resistance. The main objective of the study was to estimate the incidence and identify risk factors for the acquisition of MARPA among individuals with CF., Methods: Five-year cohort study of individuals followed in the Cystic Fibrosis Foundation Registry from 1998 through 2002., Results: Demographics, anthropometrics, spirometry, respiratory culture results, comorbidities, antibiotic usage, and hospitalizations were collected. Of the 4,293 patients with P aeruginosa infection during the study period, MARPA developed in 341. The overall incidence of MARPA was 1.8%/yr. Independent risk factors for MARPA included CF-related diabetes mellitus (hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.11 to 2.43), long-term inhaled tobramycin usage (HR, 2.08; 95% CI, 1.56 to 2.77), and care at a CF center with a baseline MARPA prevalence in the top quartile (HR, 2.00; 95% CI, 1.31 to 3.04). Frequent courses of IV antibiotics and repeated hospitalizations were also found to independently increase the risk for MARPA., Conclusions: Infection with MARPA is common among patients with CF. Diabetes, long-term inhaled tobramycin usage, and frequent acute pulmonary exacerbations requiring hospitalization or IV antibiotics increase the risk for MARPA. Receiving CF care at a center with a high prevalence of resistant Pseudomonas also increases the risk for MARPA in patients with CF. Further study is needed to investigate the mechanisms of acquiring resistant strains and the clinical impact of MARPA on CF outcomes.

Rationale: Lung compliance has been found to be low in patients with chronic diaphragmatic weakness or paralysis but has not been well-studied in patients with amyotrophic lateral sclerosis (ALS). Noninvasive positive-pressure ventilation (NPPV) prolongs survival in ALS patients but may also have additional beneficial effects., Objectives: This study evaluated static expiratory lung compliance (CL) in subjects with ALS and determined the effect of lung inflation with supramaximal inflation on CL., Design: This was a prospective trial comparing CL before and after supramaximal lung inflation via mouthpiece-delivered positive pressure., Setting: A single university medical center with an multidisciplinary ALS center., Participants: Fourteen subjects with ALS were compared to 4 healthy volunteers., Interventions: Subjects underwent a battery of pulmonary function tests including for CL. Then they used positive pressure administered via a mouthpiece set to 10 cm H2O above their maximal static recoil pressure for 5 min. The CL measurement was then repeated., Results: The mean (+/- SD) baseline CL was reduced (164.1 +/- 82.1 mL/cm H2O) in subjects with ALS and was significantly lower than that in healthy volunteers (237.5 mL/cm H2O; p = 0.04). CL increased significantly in subjects with evidence of diaphragm weakness (change in CL, 11.3 +/- 16.7 mL/cm H2O; p = 0.03). Healthy volunteers did not have an increase in CL., Conclusions: Patients with ALS and diaphragmatic weakness have reduced CL, and brief supramaximal inflation increases CL. These findings suggest that atelectasis or increased alveolar surface forces are present in ALS patients and that these patients will have increased work of breathing. Some of the beneficial effects demonstrated with NPPV therapy may be through its effects on CL and the work of breathing.

Study Objectives: To determine which respiratory function tests best predicted diaphragmatic strength in patients with amyotrophic lateral sclerosis., Patients and Methods: Patients referred for pulmonary evaluation were included (n = 25) if they underwent measurement of transdiaphragmatic pressure (Pdi) and one or more of the following on the same day: upright FVC, supine FVC, upright FEV(1), supine FEV(1), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and PaCO(2). Abdominal paradox and use of accessory muscles were also assessed. Bivariate analyses were performed using simple linear regression. Sensitivity and specificity of the potential predictors to detect an abnormal Pdi (< 70 cm H(2)O) were calculated., Setting: Pulmonary function laboratory of an academic medical center., Results: Upright FVC, FEV(1), and MEP were all significantly correlated with Pdi, while MIP and PaCO(2) were not. Supine FVC was the most highly correlated predictor of Pdi (R(2) = 0.76). A cutoff of supine FVC that was < 75% predicted was 100% sensitive and specific for predicting an abnormally low Pdi. Accessory muscle use and abdominal paradox were both significantly associated with Pdi, and the presence of accessory muscle use had a sensitivity of 84% and a specificity of 100% for detecting a low Pdi., Conclusions: Our findings suggest that supine FVC is an excellent and simple test of diaphragmatic weakness.