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The Japanese Respiratory Society (JRS) has recommended spirometry for the diagnosis of respiratory diseases. It is indispensable for the confirmation of airflow obstruction by spirometry in chronic obstructive pulmonary disease (COPD) diagnosis. However, the coronavirus disease 2019 (COVID-19) pandemic has made it difficult for many clinics to perform spirometry as it may lead to possible aerosol infections. Thus, the diagnosis of COPD, especially in the early stage, has become difficult. To overcome this situation, JRS issued a "Flowchart of Working Diagnosis and Management of COPD during the COVID-19 Pandemic". This flowchart may help physicians provisionally diagnose COPD patients without performing spirometry, offering them appropriate intervention even in epidemic and pandemic situations., Competing Interests: Conflict of Interest Yoko Shibata: Lecture fees; GSK Japan, Boehringer Ingelheim Japan, AstraZeneca Japan, and Novartis Japan. Advisory Board: GSK Japan. Shigeo Muro: Honorarium from Boehringer Ingelheim Japan, AstraZeneca Japan, and Novartis Japan. Advisory Board: GSK Japan and AstraZeneca Japan. Akihito Yokoyama: Honorarium from Boehringer Ingelheim Japan, AstraZeneca Japan, GSK Japan, Sanofi Japan, and Novartis Japan. Shu Hashimoto: Lecture fees; AstraZeneca Japan, Boehringer Ingelheim Japan., (Copyright © 2021 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Objective: The purpose of the present study was to investigate the values of the serum (1,3)-β-D-glucan test (G test) alone, the galactomannan test (GM test) alone, and their combination in the diagnosis of invasive fungal rhinosinusitis (IFRS)., Methods: The present study retrospectively analysed the clinical data of 98 patients who were preliminarily diagnosed with "space-occupying lesions in nose". Of these 98 patients, 88 received the G test, 55 received the GM test, and 45 received both. A pathology analysis was used as the gold standard to diagnose IFRS. All data were analysed using SPSS 19.0., Results: The sensitivities (Se) of the G and GM tests alone were 60.0% and 28.6%, respectively, whereas the specificities (Sp) were 92.3% and 93.8%, respectively. Moreover, the positive predictive values (PPV) of the G and GM tests alone were 50.0% and 40.0%, respectively, and the negative predictive values (NPV) were 94.7% and 90.0%, respectively. In addition, the diagnostic odds ratios (DOR) were 18.0 and 6.0, respectively, and the Kappa values were 0.48 (P < 0.05) and 0.25 (P > 0.05), respectively. When the G and GM tests were parallel combined, the Se was 66.7%, the Sp was 92.3%, the PPV was 57.1%, the NPV was 94.7%, the DOR was 24.0, and the Kappa value was 0.55 (P < 0.05). The present study was unable to evaluate the serial diagnosis due to the lack of patients testing positive., Conclusions: The G/GM tests exhibited low Se and PPV when used to diagnose IFRS, while high Sp and NPV. Parallel diagnosis improved the diagnostic Se and DOR values., (Copyright © 2020. Published by Elsevier Inc.)

Background: Eosinophilic chronic rhinosinusitis (ECRS) is often complicated by asthma and can be difficult to diagnose. This study aimed to clarify the usefulness of the self-administered odor questionnaire (SAOQ) and visual analog scale (VAS) to identify olfactory disorders in patients with asthma., Methods: This retrospective study was conducted on patients with asthma who were referred to the Otolaryngology clinic between May and September 2018. The treatment step of asthma, asthma control test (ACT), pulmonary function test, peripheral blood eosinophils, and fractional exhaled nitric oxide (FeNO) were analyzed. ECRS was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study score. Olfactory dysfunction was evaluated using the SAOQ and VAS for olfactory disorders., Results: The study included 56 patients (18 males and 38 females), who were divided into two groups; those with ECRS (n = 18) and those without ECRS (n = 38). Age, sex, treatment step, ACT score, and pulmonary function were not significantly different between the groups. The ECRS group had a significantly higher FeNO value (89.1 ppb vs. 39.1 ppb) and a significantly lower SAOQ score (40.1% vs. 96.1%). The area under the receiver operating characteristic curve for the efficacy of ECRS diagnosis was 0.88, 0.889, 0.799, and 0.757 for SAOQ, VAS, blood eosinophil count, and FeNO, respectively., Conclusion: The SAOQ and VAS scores were useful tools that presented similar results to the blood eosinophil count and FeNO, and may help to improve the diagnosis of ECRS in patients with asthma., Competing Interests: Conflict of interest The authors have no conflicts of interest., (Copyright © 2020 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Background: In adult patients with bronchiectasis (BE) the identification of the underlying aetiology may be difficult. In a new patient with BE the performance of a panel of tests is recommended, even though this practice may be expensive and the level of evidence supporting is low. We aimed to identify a panel of variables able to predict the aetiological diagnosis of BE., Methods: Our prospective study derived from our real-life experience on the management of adult stable BE outpatients. We recorded variables concerning clinical, radiological, microbiological and laboratory features. We identified five groups of aetiological diagnosis of BE (idiopathic, post-infective, COPD, asthma and non-common diseases [immunodeficiency or other rare conditions]). Multivariate models were used to identify predictors of each aetiological diagnosis. The suitability of performing a specific test for the diagnosis was also considered., Results: We enrolled 354 patients with a new diagnosis of BE. Patients with different aetiological causes differed significantly with regard to age, sex, smoking habit, comorbidities, dyspnoea perception, airflow obstruction and severity scores. Various predictors were assessed, including sex, previous respiratory infections, diffuse localization of BE, risk scores, and laboratory variables (sodium and eosinophils). The levels of autoantibodies or immunoglobulins were reserved for the diagnosis of non-common disease., Conclusion: Our research confirms that some predictors are specific for the aetiological diagnosis of BE. The possibility of integrating this information may represent a useful tool for the diagnosis. The execution of certain specific tests should be reserved for patients with a non-common disease., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Unified airway disease where upper respiratory tract inflammation including chronic rhinosinusitis (CRS) affects lower airway disease is known from asthma, bronchiectasis, cystic fibrosis and primary ciliary dyskinesia but little is known about CRS and health related quality of life in COPD. We investigate firstly, the prevalence of CRS in COPD. Secondly the impact of CRS on HRQoL. Thirdly, risk factors for CRS in COPD., Methods: cross-sectional study of CRS in 222 COPD patients from 2017 to 2019 according to EPOS2012/2020 and GOLD2019 criteria. Patients completed the COPD assessment test (CAT), Medical Research Council dyspnea scale and Sinonasal outcome test 22 (SNOT22) and questions on CRS symptoms. They then had a physical examination including flexible nasal endoscopy, CT-sinus scan and HRCT-thorax., Results: 22.5% of COPD patients had CRS and 82% of these were undiagnosed prior to the study. HRQoL (CAT, SNOT22 and the SNOT22-nasal symptom subscore) was significantly worse in COPD patients with CRS compared with those without CRS and healthy controls. Multiple logistic regression analysis suggests that the most likely candidate for having CRS was a male COPD patient who actively smoked, took inhaled steroids, had a high CAT and SNOT22&#95;nasal symptom subscore., Discussion: the largest clinical study of CRS in COPD and the only study diagnosing CRS according to EPOS and GOLD. This study supports unified airway disease in COPD. The SNOT22&#95;nasal symptoms subscore is recommended as a standard questionnaire for COPD patients and patients at risk should be referred to an otorhinolaryngologist., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naïve children is unclear. We report polysomnography outcomes of surgically naïve children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy., Methods: This study is a case series of 62 surgically naïve children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test., Results: Children were on average 5.9 (± 5.5, 0.2-18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p < 0.01) and oxygen nadir (82 to 87, p < 0.01). Thirty-eight (61%) had a postoperative oAHI < 5; 16 (21%) had a postoperative oAHI < 2., Conclusion: DISE resulted in intervention other than AT in 58% of surgically naïve children at high risk for persistent OSA after AT. DISE-directed intervention resulted in significant mean improvement in postoperative OSA.

Bronchiolitis obliterans (BO) is a rare, chronic form of obstructive lung disease, often initiated with injury of the bronchiolar epithelium followed by an inflammatory response and progressive fibrosis of small airways resulting in nonuniform luminal obliteration or narrowing. The term BO comprises a group of diseases with different underlying etiologies, courses, and characteristics. Among the better recognized inciting stimuli leading to BO are airway pathogens such as adenovirus and mycoplasma, which, in a small percentage of infected children, will result in progressive fixed airflow obstruction, an entity referred to as postinfectious bronchiolitis obliterans (PIBO). The present knowledge on BO in general is reasonably well developed, in part because of the relatively high incidence in patients who have undergone lung transplantation or bone marrow transplant recipients who have had graft-versus-host disease in the posttransplant period. The cellular and molecular pathways involved in PIBO, while assumed to be similar, have not been adequately elucidated. Since 2016, an international consortium of experts with an interest in PIBO assembles on a regular basis in Geisenheim, Germany, to discuss key areas in PIBO which include diagnostic workup, treatment strategies, and research fields., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Silvija-Pera Jerkic et al.)

The COPD Assessment Test (CAT) is in widespread use for the evaluation of patients with chronic obstructive pulmonary disease (COPD). We assessed whether the CAT items carry additional information beyond the sum score regarding COPD characteristics including emphysema. Patients of GOLD grades 1 to 4 from the COPD cohort COSYCONET (German COPD and Systemic Consequences - Comorbidities Network) with complete CAT data were included (n = 2270), of whom 493 had chest CT evaluated for the presence of emphysema. Comorbidities and lung function were assessed following standardised procedures. Cross-sectional data analysis was based on multiple regression analysis of the single CAT items against a panel of comorbidities, lung function, or CT characteristics (qualitative score, 15th percentile of mean lung density), with age, BMI and gender as covariates. This was supported by exploratory factor analysis. Regarding the relationship to comorbidities and emphysema, there were marked differences between CAT items, especially items 1 and 2 versus 3 to 8. This grouping was basically confirmed by factor analysis. Items 4 and 5, and to a lower degree 1, 2 and 6, appeared to be informative regarding the presence of emphysema, whereas the total score was not or less informative. Regarding comorbidities, similar findings as for the total CAT score were obtained for the modified Medical Research Council scale (mMRC) which was also informative regarding emphysema. Our findings suggest that the usefulness of the CAT can be increased if evaluated on the basis of single items which may be indicating the presence of comorbidities and emphysema., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Endotracheal intubation and invasive mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). Laryngeal oedema is a known complication of intubation that may cause airway obstruction in a patient on extubation. To date, the only test available to predict this complication is the cuff leak test (CLT); however, its diagnostic accuracy and utility remains uncertain. Herein, we report the protocol for the CuffLeak and AirwayObstruction in MechanicallyVentilated ICU Patients (COMIC) pilottrial., Methods and Analysis: This will be a multicentred, pragmatic, pilot randomised controlled trial (RCT). We will enrol 100 mechanically ventilated patients in the ICU who are deemed ready for extubation. We will exclude patients at a high risk of laryngeal oedema. All enrolled patients will have a CLT done before extubation. In the intervention arm, the results of the CLT will be communicated to the bedside physician, and decision to extubate will be left to the treating team. In the control arm, respiratory therapist will not communicate the results of the CLT to the treating physician, and the patient will be extubated regardless of the CLT result. Randomisation will be done in a 1:1 allocation ratio, stratified by size of the endotracheal tube and duration of invasive mechanical ventilation.Although we will examine all clinical outcomes relevant for the future COMIC RCT, the primary outcomes of the COMIC pilottrial will be feasibility outcomes including: consent rate, recruitment rate and protocol adherence. Clinical outcomes include postextubation stridor, reintubation, emergency surgical airway, ICU mortality, in hospital mortality, duration of mechanical ventilation and ICU length of stay in days., Ethics and Dissemination: The Hamilton Integrated Research Ethics Board, Imam Abdulrahman Bin Faisal University Institutional Review Board and Bioethical Commission of the Jagiellonian University approved this study. The trial results will be disseminated via publication in peer-reviewed journals., Trial Registration Number: NCT03372707., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Preoperative airway evaluation in children is an important part of routine preanesthetic evaluation before surgery. External airway measurements, viz., thyromental, mentohyoid, and sternomental distances, while being growth dependent, could identify pediatric patients with potentially difficult airways., Objectives: This study was conducted to validate the age- and height-based formulae, derived from a previous study conducted in our institute, to predict thyromental distance, sternomental distance, and mentohyoid distance in relation with the height and age of pediatric patients., Design: Prospective cross-sectional single arm observational study., Setting: Tertiary level university teaching hospital from July 2015 to December 2016., Patients: Children (202) in the age group of 3-15 years with no obvious external airway anomaly scheduled for elective surgery under general anesthesia., Outcomes Measured: The thyromental, mentohyoid, and sternomental distances were measured preoperatively. The same parameters were then calculated based on age- and height-related formulae derived in the earlier study., Results: Bland-Altman analysis of the sample patients showed a mean difference (bias) between measured and calculated values ranging from 0.14 to -0.60 (3 - 13%). Overall agreement in terms of bias were found to be more with height-based equation for mentohyoid distance and thyromental distance and age-based equation for sternomental distance., Conclusion: Our study validates the formulae derived in the earlier study to predict thyromental, mentohyoid, and sternomental distances in children with no obvious external airway anomalies. Further studies are needed to extend the applicability of these formulae in obese children and those with craniofacial anomalies coming for general anesthesia and surgery., Competing Interests: There are no conflicts of interest.

Background: We obtain summary estimates of the accuracy of additional objective tests for the diagnosis of adult asthma using systematic review and meta-analysis of diagnostic test accuracy studies., Methods: Medline, Embase, and other relevant electronic databases were searched for papers published between January 1989 and December 2016. Studies were included if they evaluated the diagnostic accuracy of objective tests, including airway reversibility (AR), airway hyperresponsiveness (AHR), and fractionated exhaled nitric oxide (FeNO) for the diagnosis of adult asthma in patients with symptoms suggestive of asthma. If papers were assessed appropriate using the adapted QUADAS-2 tool, meta-analysis was conducted using the hierarchical bivariate model. This hierarchical model accounts for both within and between study variability., Results: Sixteen studies reported the performance of the evaluated objective tests at presentation. For diagnosis of adult asthma, overall sensitivity and specificity for AR were 0.39 (95% confidence interval [CI] 0.18 to 0.66) and 0.95 (95% CI 0.86 to 1.00); for AHR, 0.86 (95% CI 0.61 to 1.00) and 0.95 (95% CI 0.77 to 1.00); for FeNO, 0.65 (95% CI 0.53 to 0.77) and 0.83 (95% CI 0.75 to 0.90). Comprehensive comparison of three diagnostic tools for adult asthma using the back-calculated likelihood rate (LR) showed that AR and AHR corresponded to a higher LR+, and AHR gave a lower LR-., Conclusions: In the current situation of no gold standard for diagnosis of adult asthma, AR and AHR are appropriate for ruling-in the true diagnosis, and AHR is superior for ruling-out a diagnosis. Since each objective test had a specific characteristic, it should be chosen depending on the situation, such as the capacity of the institution and the conditions of patients., (Copyright © 2018 Japanese Society of Allergology. Production and hosting by Elsevier B.V. All rights reserved.)

Background: Immunocompromised children are at high risk of rapid deterioration and of developing life-threatening pulmonary infections. Etiologies in this setting are diverse, including those that are infectious and noninfectious, and many etiologies may coexist. Accurate diagnosis is required for the rational use of medications. Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) can identify infectious causes in this population., Objectives: The aims of this study were to evaluate diagnostic rate, safety, and changes in treatment following FOB with BAL, when applied with advanced laboratory diagnostic techniques., Patients and Methods: We reviewed the records of children who underwent FOB with BAL during the period spanning from 2006 to 2014 in the Hematology-Oncology Department. BAL samples were processed in microbiology, virology, cytology, and molecular laboratories., Results: Antimicrobials were initiated in 91 of 117 children. BAL yielded an infectious etiology in 55 episodes. Management was altered in 74 patients following a positive (40/55) or a negative (30/54) result (4 patients had missing data). No severe complications associated with the procedures occurred., Conclusions: Most immunocompromised patients with pulmonary manifestations are treated empirically with multiple medications. Evaluation FOB/BAL is a useful diagnostic tool, and seems to have changed the course of therapy in more than half of patients, by initiation or cessation of treatment. FOB/BAL is a safe diagnostic tool for the evaluation of pulmonary manifestations in this setting.

Bronchiectasis are defined as an irreversible focal or diffuse dilatation of the bronchi and can be associated with significant morbidity. The prevalence is currently increasing, probably due to an increased use of thoracic computed tomography (CT). Indeed, the diagnosis relies on imaging and chest CT is the gold standard technique. The main diagnosis criterion is an increased bronchial diameter as compared to that of the companion artery. However, false positives are possible when the artery diameter is decreased, which is called pseudo-bronchiectasis. Other features such as the lack of bronchial tapering, and visibility of bronchi within 1cm of the pleural surface are also diagnostic criteria, and other CT features of bronchial disease are commonly seen. Thoracic imaging also allows severity assessment and long-term monitoring of structural abnormalities. The distribution pattern and the presence of associated findings on chest CT help identifying specific causes of bronchiectasis. Lung MRI and ultra-low dose CT and are promising imaging modalities that may play a role in the future. The objectives of this review are to describe imaging features for the diagnosis and severity assessment of bronchiectasis, to review findings suggesting the cause of bronchiectasis, and to present the new developments in bronchiectasis imaging., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: The aims of this study were to investigate the prevalence of allergic rhinitis (AR) and the accuracy of the International Study of Asthma and Allergies in Childhood (ISAAC) questions for diagnosis of AR, in Korean children. Methods: Students that participated in an allergic disease prevalence survey in 2010⁻2017 were evaluated ( n = 18,425) using questionnaires and a skin prick test (SPT). Age-stratified (5-7, 8-10, 11-13, 14-16 years) prevalence of four rhinitis questions, accuracy of the questions for AR, and proportion of comorbidities in the AR and non-AR (NAR) groups were evaluated. Results: The proportion of students responding to the questionnaire that ever had symptoms of AR since birth, that is, the prevalence of "symptom, ever" was 47.6%. Based on the questionnaire and SPT, overall prevalence of AR and NAR were 21% and 26.5%, respectively. The sensitivity, specificity, and accuracy of "symptom, ever" were 57.5%, 58.4%, and 58.1%, respectively, and those of "diagnosis, ever", who had ever been diagnosed with AR, were 39.8%, 76.9%, and 63.4%, respectively. Questionnaire-based asthma, atopic dermatitis, and food allergy were significantly associated with the AR group compared to the NAR group. Conclusions: Since the AR accuracy of the questionnaire is about 60%, it should be considered that the questionnaire based survey overestimates the true prevalence of AR in Korean children.

Substantial over-diagnosis and under-diagnosis of asthma in adults and children has recently been reported. As asthma is mostly diagnosed in non-specialist settings, a clinical prediction model (CPM) to aid the diagnosis of asthma in primary care may help improve diagnostic accuracy. We aim to systematically identify, describe, compare, and synthesise existing CPMs designed to support the diagnosis of asthma in children and adults presenting with symptoms suggestive of the disease, in primary care settings or equivalent populations. We will systematically search Medline, Embase and CINAHL from 1 January 1990 to present. Any CPM derived for use in a primary care population will be included. Equivalent populations in countries without a developed primary care service will also be included. The probability of asthma diagnosis will be the primary outcome. We will include CPMs designed for use in clinical practice to aid the diagnostic decision making of a healthcare professional during the assessment of an individual with symptoms suggestive of asthma. We will include derivation studies, and external model validation studies. Two reviewers will independently screen titles/abstracts and full texts for eligibility and extract data from included papers. The CHARMS checklist (or PROBAST if available) will be used to assess risk of bias within each study. Results will be summarised by narrative synthesis with meta-analyses completed if possible. This systematic review will provide comprehensive information about existing CPMs for the diagnosis of asthma in primary care and will inform the development of a future diagnostic model.

Rationale: A major barrier to a more complete understanding of acute respiratory distress syndrome (ARDS) pathophysiology is the inability to sample the distal airspace of patients with ARDS. The heat moisture exchanger (HME) filter is an inline bacteriostatic sponge that collects exhaled moisture from the lungs of mechanically ventilated patients., Objectives: To test the hypothesis that HME filter fluid (HMEF) represents the distal airspace fluid in patients with ARDS., Methods: Samples of HMEF were collected from 37 patients with acute pulmonary edema (either from ARDS or hydrostatic causes [HYDRO; control subjects]). Concurrent undiluted pulmonary edema fluid (EF) and HMEF were collected from six patients. HMEF from 11 patients (8 ARDS and 3 HYDRO) were analyzed by liquid chromatography-coupled tandem mass spectometry. Total protein (bicinchoninic acid assay), MMP-9 (matrix metalloproteinase-9), and MPO (myeloperoxidase) (ELISA) were measured in 29 subjects with ARDS and 5 subjects with HYDRO. SP-D (surfactant protein-D), RAGE (receptor for advanced glycation end-products) (ELISA), and cytokines (IL-1β, IL-6, IL-8, and tumor necrosis factor-α) (electrochemiluminescent assays) were measured in six concurrent HMEF and EF samples., Measurements and Main Results: Liquid chromatography-coupled tandem mass spectrometry on concurrent EF and HMEF samples from four patients revealed similar base peak intensities and m/z values indicating similar protein composition. There were 21 significantly elevated proteins in HMEF from patients with ARDS versus HYDRO. Eight proteins measured in concurrent EF and HMEF from six patients were highly correlated. In HMEF, total protein and MMP-9 were significantly higher in ARDS than in HYDRO., Conclusions: These data suggest that HMEF is a novel, noninvasive method to accurately sample the distal airspace in patients with ARDS.

Pulmonary resection can be associated with a significant risk of morbidity and mortality, which depends on the nature and extent of pulmonary resection but also on the patient himself. This risk can be apprehended by a preoperative assessment which estimates the immediate operative risk as well as the physiological state and the post-operative quality of life which can require more conservative therapies. Currently, preoperative exploration of a patient is based on various technological tools, which can range from simple electrocardiogram or simple spirometry to a complex exploration such as a cardiorespiratory effort test. These multiple evaluation tools require the rationalization of good practice processes according to international recommendations, taking into account the patient's specificity and the country context. This approach makes it possible to prioritize examinations according to their availability and accessibility in order to identify patients with high operative risk and to offer them an appropriate therapeutic choice.

Background: Massive pulmonary emboli can cause an abrupt onset of symptoms simultaneous with large pulmonary artery occlusions. In contrast, the temporal relationship between pulmonary vascular occlusion by smaller emboli and the development of symptoms of pulmonary infarction is unknown. We describe the time interval between embolization and the onset of clinical symptoms and signs compatible with pulmonary infarction., Methods: We examined the records of 56 patients with hereditary hemorrhagic telangiectasia (HHT) who underwent therapeutic balloon embolization of pulmonary arteriovenous malformation (PAVM) in a single center after noting that some of them experienced symptoms and signs compatible with pulmonary infarction. Because both the times of embolization and the onset of clinical symptoms were documented in medical records, we were able to calculate the time interval between embolic occlusion of vessels and the onset of symptoms., Results: The records of 56 patients who underwent therapeutic embolization for HHT were examined. Five patients experienced a single episode of pleuritic pain postembolization, and one patient experienced episodes of pleuritic pain after each of two separate embolization procedures. Four of these pleuritic pain events evolved into a complex compatible with pulmonary infarction. The time intervals between embolization and the onset of pleuritic pain in those experiencing the infarction symptoms and signs were 24 hours, 48 ± 4 hours, 65 hours, and 67 hours, respectively., Conclusions: The clinically silent time interval between embolization of a pulmonary artery and the onset of symptoms and signs compatible with lung infarction is 24 hours or greater., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Inspiratory flow limitation (IFL) is a critical symptom of sleep breathing disorders. A characteristic flattened flow-time curve indicates the presence of highest resistance flow limitation. This study involved investigating a real-time algorithm for detecting IFL during sleep. Three categories of inspiratory flow shape were collected from previous studies for use as a development set. Of these, 16 cases were labeled as non-IFL and 78 as IFL which were further categorized into minor level (20 cases) and severe level (58 cases) of obstruction. In this study, algorithms using polynomial functions were proposed for extracting the features of IFL. Methods using first- to third-order polynomial approximations were applied to calculate the fitting curve to obtain the mean absolute error. The proposed algorithm is described by the weighted third-order (w.3rd-order) polynomial function. For validation, a total of 1,093 inspiratory breaths were acquired as a test set. The accuracy levels of the classifications produced by the presented feature detection methods were analyzed, and the performance levels were compared using a misclassification cobweb. According to the results, the algorithm using the w.3rd-order polynomial approximation achieved an accuracy of 94.14% for IFL classification. We concluded that this algorithm achieved effective automatic IFL detection during sleep.

We developed a high-throughput bead-based suspension array for simultaneous detection of 20 respiratory tract pathogens in clinical specimens. Pathogen-specific genes were amplified and hybridized to probes coupled to carboxyl-encoded microspheres. Fluorescence intensities generated via the binding of phycoerythrin-conjugated streptavidin with biotin-labeled targets were measured by the Luminex 100 bead-based suspension array system. The bead-based suspension array detected bacteria in a significantly higher number of samples compared to the conventional culture. There was no significant difference in the detection rate of atypical pathogensatypical pathogens or viruses between the bead-based suspension array and real-time PCR. This technology can play a significant role in screening patients with pneumonia., (© 2016 by the Society for Experimental Biology and Medicine.)

Primary ciliary dyskinesia (PCD) is a rare, heterogeneous, recessive, genetic disorder of motile cilia, leading to chronic upper and lower respiratory symptoms. Prevalence is estimated at around 1:10,000, but many patients remain undiagnosed, whereas others receive the label incorrectly. Proper diagnosis is complicated by the fact that the key symptoms, such as wet cough, chronic rhinitis, and recurrent upper and lower respiratory infection, are common and nonspecific. There is no single gold standard test to diagnose PCD. Currently, the diagnosis is made in patients with a compatible medical history after a demanding combination of tests including nasal nitric oxide, high-speed video microscopy, and transmission electron microscopy and genetic and ciliary culture testing. These tests are costly and need sophisticated equipment and experienced staff, restricting use to highly specialized centers. Therefore, it would be desirable to have a screening test for identifying those patients who should undergo detailed diagnostic testing. Three recent studies focused on potential screening tools: one study assessed the validity of nasal nitric oxide for screening, and two studies developed new symptom-based screening tools. These simple tools are welcome, and it is hoped that they will assist physicians in determining whom to refer for definitive testing. However, they have been developed in tertiary care settings, where 10 to 50% of tested patients have PCD. The sensitivity and specificity of the tools are reasonable, but positive and negative predictive values may be poor in primary or secondary care settings. Although these studies are an important step toward an earlier diagnosis of PCD, more remains to be done before we have tools tailored to different health care settings.

Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located., (Copyright © 2016 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Fibrous dysplasia of bone is a rare benign lesion characterized by the coexistence of a fibrous tissue and an immature osteogenesis. Costal localization is rare and may be monostotic or polyostotic. The diagnosis may be suspected based on clinical and radiological findings. Facing the development of radiological investigations, we tried to highlight the diagnostic role of the microscopic examination through the experience of our department., Methods: We describe a retrospective study about 12 costal fibrous dysplasias diagnosed over a 17-year-period. Clinical records were retrieved from the department of thoracic surgery of the same hospital., Results: Costal fibrous dysplasia is equally observed in men and women with predominance in the third and fourth decades. Clinical symptoms consist mainly in chest pain. Physical examination was normal in almost all cases. Based on the radiological findings, the diagnosis was suspected in 33% of the cases. Microscopic examination highlighted the diagnosis in all cases but it was challenging in one case and necessitated a multi-disciplinary approach. The difficulties encountered were due to artifact decalcification., Conclusion: Costal fibrous dysplasia is a benign lesion which diagnosis is based on microscopic features. Radiologic investigations show nonspecific features but allow to rule out a malignant tumor. The outcome of the patients is generally good except in rare cases with a malignant transformation., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Diagnosing primary ciliary dyskinesia is difficult. With no reference standard, a combination of tests is needed; most tests require expensive equipment and specialist scientists. We review the advances in diagnostic testing over the past hundred years, with emphasis on recent advances. We particularly focus on use of high-speed video analysis, transmission electron microscopy, nasal nitric oxide and genetic testing. We discuss the international efforts that are in place to advance the evidence base for diagnostic tests., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Obstructive sleep apnea (OSA) is a clinically significant condition associated with an increase in cardiovascular risk, daytime sleepiness and in risk of accidents. Diagnosis usually relies on a detailed anamnesis and an ambulatory nocturnal polygraphy. Suspecting the presence of OSA or a persisting unclear daytime sleepiness in need of treatment further polysomnographic diagnosis should be performed in a specialized sleep center. Cardiorespiratory polysomnography is the diagnostic gold standard in differentiating sleep-related breathing and movement disorders., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: Diagnosing childhood tuberculosis requires a strong diagnostic suspicion due to its paucibacillary manifestation. Different scoring systems and algorithms have been developed to deal with such challenge skillfully. These include the Keith Edwards diagnostic score and Stegen's criteria modified by Toledo (Stegen-Toledo)., Objectives: To compare the predictive ability of the Keith Edwards diagnostic score to that of the Stegen-Toledo scoring system. To estimate the predictive diagnostic ability of chest X-rays individually., Population, Material and Methods: Patients seen at the Department of Pediatric Pulmonology of the City of Buenos Aires between 2009 and 2012. A² test was used to analyze the predictive diagnostic ability, and performance was compared using the extended McNemar test., Results: Keith Edwards: 19.62% sensitivity, 97.62% specificity (p < 0.0001). Stegen-Toledo: 43.54% sensitivity, 97.82% specificity (p < 0.0001). Sensitivity was significantly different between both scoring systems (p < 0.05), but no differences were observed in terms of specificity. Chest X-ray: 91.15% sensitivity, 87.72% specificity (p < 0.0001)., Conclusion: The Keith Edwards scoring system showed a lower diagnostic sensitivity than the Stegen-Toledo score in this group of patients, with no differences observed in terms of specificity. The chest X-ray showed a 91.15% sensitivity to diagnose tuberculosis in this group of patients.

Background: A low FEV1/FVC from post-bronchodilator spirometry is required to diagnose COPD. Both the FEV1 and the FVC can vary over time; therefore, individuals can be given a diagnosis of mild COPD at one visit, but have normal spirometry during the next appointment, even without an intervention., Methods: We analyzed two population-based surveys of adults with spirometry carried out for the same individuals 5-9 years after their baseline examination. We determined the factors associated with a change in the spirometry interpretation from one exam to the next utilizing different criteria commonly used to diagnose COPD., Results: The rate of an inconsistent diagnosis of mild COPD was 11.7% using FEV1/FVC <0.70, 5.9% using FEV1/FEV6

The symposium consisted of four parts: history of lung function tests, nitric oxide for diagnosis and monitoring of bronchial asthma, radiological and functional changes of the lung in COPD, and combined pulmonary fibrosis and emphysema (CPFE) occasionally showing almost normal results in lung function tests. The history of lung function tests was presented by Dr. Naoko Tojo of the Tokyo Medical and Dental University. Nitric oxide tests in clinical use for diagnosis and monitoring of bronchial asthma were presented by Dr. Hiroyuki Nagase of Teikyo University. Radiological and functional changes of the lung in COPD were presented by Dr. Shigeo Muro of Kyoto University. Clinical features of combined pulmonary fibrosis and emphysema and their associated lung function were presented by Dr. Daiya Takai of the University of Tokyo. I hope that discussing the history of lung function tests until the present was useful for many medical technologists. (Review).

The spectrum of pulmonary diseases that can affect human immunodeficiency virus (HIV)-infected patients is wide and includes both HIV and non-HIV-related conditions. Opportunistic infections and neoplasms remain a major concern even in the current era of combination antiretroviral therapy. Although these diseases have characteristic clinical and radiological features, there can be considerable variation in these depending on the patient's CD4 lymphocyte count. The patient's history, physical examination, CD4 count and chest radiograph features must be considered in establishing an appropriate diagnostic algorithm. In this article, we propose different diagnostic approaches HIV infected to patients with respiratory symptoms depending on their clinico-radiological pattern., (Copyright © 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: In advance of endoscopic procedures, an evaluation to assess the risk of sedation is performed by the gastroenterologist. Based on regulations, gastroenterologists are required to perform an airway assessment. At this time, data supporting this regulation are limited; therefore, we evaluated airway assessment accuracy by gastroenterologists before endoscopic procedures., Methods: A retrospective, single tertiary care center study was performed from May 2012 through August 2013. Patients who underwent an endoscopy or colonoscopy performed at the University of Missouri-Columbia with documented Mallampati scores were included in the analysis. Three primary cohorts of patients were included in our study: gastroenterologist versus anesthesiologist, gastroenterologist versus other gastroenterologists, and gastroenterologists versus themselves. Data were collected and recorded for patient age, body mass index, and Mallampati score. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement., Results: For gastroenterologists versus anesthesiologists and versus other gastroenterologists, the agreement on Mallampati scores was poor (weighted kappa index 0.103, 95% confidence interval [CI] -0.0126 to 0.219; percentage of agreement 42% and 0.120, 95% CI -0.0211 to 0.260; percentage of agreement 46%, respectively). For gastroenterologists versus themselves for the same patient, the agreement on Mallampati scores was only moderate (weighted kappa index 0.420, 95% CI 0.119-0.722; percentage of agreement 65%)., Conclusions: Gastroenterologists performing a preprocedure assessment using Mallampati scores have poor agreement with anesthesiologists and colleagues and only moderate agreement with themselves.

The etiological diagnosis of diffuse interstitial lung disease (ILD) is based on the integration of simple information gathered by interview, physical examination and discriminating arguments made by some investigations of the lower respiratory tract (HR-CT scan, pulmonary function tests, biological and bronchoalveolar lavage results). Obtaining the diagnosis of ILD is an important step but lung biopsy is rarely necessary: the key of ILD etiological diagnosis lies to obtain optimal information while imposing minimal patient aggression. The diagnostic approach is best when the case is subject to a multidisciplinary discussion between clinician, radiologist and pathologist experienced in the field of ILD.

Unlabelled: The aim of the study was to develop a culturally adapted translation of the 12-item smell identification test from Sniffin' Sticks (SS-12) for the Estonian population in order to help diagnose Parkinson's disease (PD)., Methods: A standard translation of the SS-12 was created and 150 healthy Estonians were questioned about the smells used as response options in the test. Unfamiliar smells were replaced by culturally familiar options. The adapted SS-12 was applied to 70 controls in all age groups, and thereafter to 50 PD patients and 50 age- and sex-matched controls., Results: 14 response options from 48 used in the SS-12 were replaced with familiar smells in an adapted version, in which the mean rate of correct response was 87% (range 73-99) compared to 83% with the literal translation (range 50-98). In PD patients, the average adapted SS-12 score (5.4/12) was significantly lower than in controls (average score 8.9/12), p < 0.0001. A multiple linear regression using the score in the SS-12 as the outcome measure showed that diagnosis and age independently influenced the result of the SS-12. A logistic regression using the SS-12 and age as covariates showed that the SS-12 (but not age) correctly classified 79.0% of subjects into the PD and control category, using a cut-off of <7 gave a sensitivity of 76% and specificity of 86% for the diagnosis of PD., Conclusions: The developed SS-12 cultural adaption is appropriate for testing olfaction in Estonia for the purpose of PD diagnosis., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Mounier-Kuhn syndrome or congenital tracheobronchomegaly is a rare clinical and radiologic condition. It is characterized by a tracheal and bronchial dilation. Fewer than 100 cases have been reported in the medical literature since the original description in 1932. The first utilization of bronchoscopy for diagnosis of this condition was recorded by Lemoine only in 1949. The cause of this condition is not clearly understood; however, histopathologic findings of atrophy of smooth muscles and elastic tissue in the trachea and main bronchi have been observed. Tracheobronchomegaly can be associated with tracheal and bronchial diverticuli.

The acoustic reflection method (ARM) is based on the analysis of the reflection of an acoustic wave in the airway, allowing the calculation of its longitudinal cross-sectional area profile and airway resistance. The ARM represents a simple, quick and totally non invasive tool for the investigation of the upper airways, requiring minimal cooperation, which makes this technique particularly suitable for children. Normal values of the minimal cross sectional area of the upper airways in children have been recently published. The ARM has shown its utility in the investigation of the nasal cavity in healthy and diseased children and of the upper airways in children with various diseases such as mucopolysaccharidosis and cystic fibrosis. This simple, rapid, and inexpensive technique seems promising for the non-invasive investigation of the whole upper airway during wakefulness in children, both in health and disease, and may constitute a complementary or alternative method to explore and follow children with anomalies of the upper airways., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: We retrospectively evaluated the invasive diagnostic techniques that were not suitable for transthoracic biopsy or bronchoscopy and the results of these techniques for advanced lung cancer cases., Methods: The files of patients operated at the Department of Thoracic Surgery, Faculty of Medicine, Pamukkale University for advanced lung cancer (stages III and IV) between 2006 and 2010 were retrospectively reviewed for the analysis of definite diagnostic methods., Results: The mean age of 59 patients who underwent invasive diagnostic techniques was 56.55 ± 9.42 years (32 to 75) and the female to male ratio was 1:4 (11 female:48 male). Mediastinoscopy was the most commonly used invasive technique with 20 patients (34%) while the second most common technique was video-assisted thoracoscopic surgery with 10 patients (17%). Thoracotomy was the most invasive diagnostic technique with four patients (6.5%)., Conclusions: Although it would be desirable to use noninvasive and minimally invasive diagnostic techniques in the diagnosis of lung cancers, we should not try to avoid using invasive diagnostic techniques in surgical practice in advanced lung cancers where other techniques may be inadequate., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: As a part of the longitudinal Chronic Obstructive Pulmonary Disease (COPD) study, Subpopulations and Intermediate Outcome Measures in COPD study (SPIROMICS), blood samples are being collected from 3200 subjects with the goal of identifying blood biomarkers for sub-phenotyping patients and predicting disease progression. To determine the most reliable sample type for measuring specific blood analytes in the cohort, a pilot study was performed from a subset of 24 subjects comparing serum, Ethylenediaminetetraacetic acid (EDTA) plasma, and EDTA plasma with proteinase inhibitors (P100)., Methods: 105 analytes, chosen for potential relevance to COPD, arranged in 12 multiplex and one simplex platform (Myriad-RBM) were evaluated in duplicate from the three sample types from 24 subjects. The reliability coefficient and the coefficient of variation (CV) were calculated. The performance of each analyte and mean analyte levels were evaluated across sample types., Results: 20% of analytes were not consistently detectable in any sample type. Higher reliability and/or smaller CV were determined for 12 analytes in EDTA plasma compared to serum, and for 11 analytes in serum compared to EDTA plasma. While reliability measures were similar for EDTA plasma and P100 plasma for a majority of analytes, CV was modestly increased in P100 plasma for eight analytes. Each analyte within a multiplex produced independent measurement characteristics, complicating selection of sample type for individual multiplexes., Conclusions: There were notable detectability and measurability differences between serum and plasma. Multiplexing may not be ideal if large reliability differences exist across analytes measured within the multiplex, especially if values differ based on sample type. For some analytes, the large CV should be considered during experimental design, and the use of duplicate and/or triplicate samples may be necessary. These results should prove useful for studies evaluating selection of samples for evaluation of potential blood biomarkers.

Background: Pleural manometry can predict the presence of trapped lung and guide large-volume thoracentesis. The current technique for pleural manometry transduces pressure from the needle or intercostal catheter, necessitating intermittent cessation of fluid drainage at the time of pressure recordings., Objectives: To develop and validate a technique for performing continuous pleural manometry, where pressure is transduced from an epidural catheter that is passed through the drainage tube to sit within the pleural space., Methods: Pleural manometry was performed on 10 patients undergoing thoracentesis of at least 500 ml, using the traditional intermittent and new continuous technique simultaneously, and pleural pressures were recorded after each drainage of 100 ml. The pleural elastance (PEL) curves and their 95% confidence intervals (CIs), derived using measurements from each technique, were compared using the analysis of covariance and Student's paired t test, respectively., Results: There was no significant difference in PEL calculated using each method (p > 0.1); however, there was a trend towards the CI for the PEL derived from the continuous method being narrower (p = 0.08). Fully automated measurement of drainage volume and pleural pressure, with real-time calculation and display of PEL, was achieved by connecting the system to a urodynamics machine., Conclusions: Pleural manometry can be transduced from an epidural catheter passed through the drainage tube into the pleural space, which gives continuous recording of the pleural pressure throughout the procedure. This allows for automated calculation and display of the pleural pressure and PEL in real time, if the system is connected to a computer with appropriate software., (© 2014 S. Karger AG, Basel)

Sleep-related complaints are extremely common in patients with cancer but often are not recognized, and even if they are, they are seldom treated. Recognizing insomnia in cancer patients is imperative, as appropriate treatment can improve quality of life.

Purpose: The term diffuse parenchymal lung disease (DPLD) refers to a group of disorders affecting the lung parenchyma that can be categorized into those of known and those of unknown etiology. Early diagnosis is important since some forms of DPLD are characterized by a rapid progression to respiratory failure. Notwithstanding the fact that recently guidelines have been published, some issues concerning the practical evaluation of a patient with suspected DPLD remain unclear., Methods: In this article we propose a practical approach to the diagnosis and differentiation of DPLD. Moreover, a critical appraisal is provided based on the current literature and frequent pitfalls are highlighted., Conclusion: we propose a practical workup, but in spite of increasing evidence concerning the diagnosis of DPLD, further studies will be needed to clarify several issues for efficient investigation of newly diagnosed patients with DPLD.

Interventional pulmonology (IP) allows comprehensive assessment of patients with benign and malignant airway, lung parenchymal and pleural disease. This relatively new branch of pulmonary medicine utilizes advanced diagnostic and therapeutic techniques to treat patients with pulmonary diseases. Endobronchial ultrasound revolutionized assessment of pulmonary nodules, mediastinal lymphadenopathy and lung cancer staging allowing minimally invasive, highly accurate assessment of lung parenchymal and mediastinal disease, with both macro- and microscopic tissue characterization including molecular signature analysis. High-spatial resolution, new endobronchial imaging techniques including autofluorescence bronchoscopy, narrow-band imaging, optical coherence tomography and confocal microscopy enable detailed evaluation of airways with increasing role in detection and treatment of malignancies arising in central airways. Precision in peripheral lesion localization has been increased through innovative navigational techniques including navigational bronchoscopy and electromagnetic navigation. Pleural diseases can be assessed with the use of non-invasive pleural ultrasonography, with high sensitivity and specificity for malignant disease detection. Medical pleuroscopy is a minimally invasive technique improving diagnostic safety and precision of pleural disease and pleural effusion assessment. In this review, we discuss the newest advances in diagnostic modalities utilized in IP, indications for their use, their diagnostic accuracy, efficacy, safety and challenges in application of these technologies in assessment of thoracic diseases., (© 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.)

OBJECTIVE. The aim of this study was to estimate the significance of nasal potential difference (NPD) in the diagnosis of cystic fibrosis (CF) in children with clinical symptoms suggestive of the disease, positive sweat test results, and/or genetically confirmed diagnosis. MATERIAL AND METHODS. NPD measurements according to the modifications by Alton were performed in 50 children with clinical CF symptoms supported by positive sweat test results, 50 children with other obstructive lung diseases, and 50 healthy children. A subgroup of 17 children with the diagnosis confirmed by 2 identified mutations in the CF transmembrane regulatory gene was analyzed individually. RESULTS. The mean NPD value recorded in 50 children with clinical symptoms of CF supported by positive sweat test results and/or genetic analysis was -28.0 mV [SD, 10.2]. The mean NPD value in the subgroup of children with 2 identified mutations in the CF gene (n=17) was more negative than in the subgroup of children with unrecognized mutations (n=33) (-37.1 mV [SD, 7.0] vs. -23.4 mV [SD, 8.3], P<0.001). The mean NPD value in patients with other obstructive lung diseases and healthy children was significantly more positive than in the group of CF children with positive sweat test results and/or identified mutations (-18.1 mV [SD, 3.6] and -15.5 mV [SD, 4.3] vs. -28.0 mV [SD, 10.2], P<0.001). The NPD cut point value for the genetically confirmed diagnosis of CF was -35.0 mV (sensitivity, 93.9%; specificity, 88.2%), while in general, the NPD prognostic value was -24.0 mV (sensitivity, 58.0%; specificity, 98.0%). CONCLUSIONS. The NPD measurement is a valuable tool for the diagnosis of CF in children, but further studies are necessary to establish NPD values related to the CF genotype and to reduce the intrasubject variability of this test.

Background: Pulmonary embolism (PE) is a fairly common condition that can be fatal. The variability of presentation sets clinician up for potentially missing the diagnosis. Routine laboratory findings are nonspecific and are not helpful in diagnosis of PE.Diagnosis is based on clinical prediction rule in combination with laboratory tests such as the D-dimers test leading to the realization ofa confirming examination., Aim: To precise the confirming examinations of PE and propose analgorithm based on clinical prediction rules in combination with D-Dimers., Methods: A Pub Med search was conducted using the following keywords: pulmonary embolism,computed tomogramphy pulmonary angiography, scintigraphy and D Dimer. The study was based on are view of 18 studies including meta analysis, reviews and original articles referring recent strategy diagnosis of pulmonary embolism., Results: Ventilation/perfusion scan is a type of examination that is used less often because it is not a widespread technology. However,it may be useful in patients who have an allergy to iodinated contrast.Ultrasonography of the legs, also known as leg doppler, in search of deep venous thrombosis (DVT) may help the diagnosis approach particularly when other exams are not available or contraindicated.This may be a valid approach in pregnancy. The gold standard for diagnosing PE is pulmonary angiography. It is used less often due to wider acceptance of multi detector CT scans, which are non-invasive.A normal ventilation/perfusion scan rules out the diagnosis of PE with negative predictive value of 97%. There is no consensus in pregnancy. Finally, the MRI has a low and insufficient sensibility to diagnose PE., Conclusion: D Dimers, multidetector CT, ventilation/ perfusion scintigraphy and ultrasonography of the legs are the most useful examinations to diagnose PE. Many algorithms were established depends on medical experience and examination availability