Akut solunum yetmezliðindeki kronik obstrüktif akciðer hastalýðý (KOAH)'lý hastalarda genellikle intübasyon ve mekanik ventilasyon ihtiyacý doðar. Ancak, invaziv mekanik ventilasyon önemli komplikasyonlara yol açabilmektedir. Bu nedenle akut solunum yetmezliðindeki KOAH'lýlarda noninvaziv yöntemlerle ventilasyon desteði gittikçe daha fazla önerilmeye baþlanmýþtýr. Biz de çalýþmamýzda KOAH akut atakta BiPAP (bi-level positive airway pressure)'ýn etkinliðini araþtýrmayý amaçladýk. Çalýþmaya 1998- 2003 yýllarý arasýnda KOAH akut atak tanýsý ile kliniðimize baþvuran ve medikal tedaviye yanýt vermeyen 40 hasta alýndý. Tüm hastalara spontan mod'ta BiPAP uygulandý. BiPAP'ýn baþlangýç basýnçlarý, IPAP 8 cmH2 O, EPAP 4 cmH2 O olacak þekilde ayarlandý. Pulse oksimetre ile saptanan SaO2 deðeri %88'in üstünde olacak þekilde oksijen verildi. Ýlk uygulamadan 30 dakika sonra arteriyel kan gazý deðerlerine bakýldý. Eðer PaCO2 deðerinde %10-20 azalma varsa IPAP deðeri 12 cmH2 O'ya, azalma yok ya da %10'dan az ise IPAP 16, EPAP 8 cmH2 O'ya kadar yükseltildi. Tedavi boyunca BiPAP basýnçlarý klinik ve kan gazý bulgularýna göre modifiye edildi. Çalýþmanýn sonucuna göre, pH, PaCO2 , PaO2 ve HCO3 deðerlerinin ortalama 11,08±7,03 gün BiPAP tedavisi sonrasýnda ilk ölçüme göre anlamlý oranda düzeldiði saptandý. 40 hastadan sadece 2'sine (%5) mekanik ventilasyon gerekti, 38'i BiPAP ile baþarýyla ventile edildi. Bizim çalýþmamýz da daha önceden yapýlan benzer çalýþmalar gibi BiPAP'ýn KOAH'da akut solunum yetmezliðinin düzelmesi ve trakeal intübasyona gerek kalmamasý açýsýndan etkinliðini göstermiþtir.

Patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure normally need to be supported with intubation and mechanical ventilation. However, while artificial ventilation has become a widely used technique, complications are increasingly being reported. This is why methods of noninvasive pressure support ventilation are being proposed more and more for COPD patients with acute respiratory failure. The objective of this study is to evaluate the efficacy of bi-level positive airway pressure support system (BiPAP) in acute exacerbation of COPD. Forthy patients admitted in the period 1998-2003 to our department with an acute exacerbation of COPD refractory to conventional (medical) treatment were studied. For all patients BiPAP was performed in the spontaneous mode. The initial settings of the BiPAP system were 8cmH2O for IPAP and 4 cmH2O for EPAP. Supplemental oxygen was delivered to maintain an oxygen saturation greater than 88% as measured by a bedside pulse oximeter. Arterial blood gases were measured at the end of 30 minutes of ventilation with the first adjustment. If PaCO2 had decreased 10 to20%, IPAP was increasd to 12 cmH2O. If PaCO2 had not decreased or the decrease was less than 10%, IPAP was increased up to 16cmH2O and EPAP to 8cmH2O. Ventilation parameters were sometimes modified in the course of the study according to clinical and blood gas analysis data. The results of the study showed a significant improvement in the mean pH, PaCO2, PaO2 and HCO3 between measurements made prior to BiPAP and those obtained after a mean 11.08 ± 7.03 days of support with optimal settings. Only 2 of the 40 patients (5%) needed tracheal intubation. The remaining 38 patients (95%) were successfully ventilated. Our study confirms the results from previous studies on the efficacy of BiPAP in avoiding endotracheal intubation and improving the immediate outcome during episodes of acute respiratory failure in COPD patients.

Abstract | Full Text PDF

Malignite, derin ven trombozu için önemli bir risk faktörüdür. Prostat, pankreas ve akciðer kanserleri sýklýkla trombozlarla birlikte görülmektedir. Venöz tromboembolizm kanserli hastalarda en sýk ölüm nedenleri arasýndadýr. Bu hastalarda trombozun tedavisi de oldukça güçtür. Bu yazýda kanserli hastalarda tromboz tedavisinin zorluklarýný ve profilaktik tedavinin önemini vurgulamak amacýyla çok sayýda trombozlarla seyreden akciðer kanserli üç olgu sunulmuþtur. Antikoagulan tedaviye baðlý komplikasyonlar nedeniyle olgularýn tedavileri tamamlanamamýþ ve bu nedenle kaybedilmiþlerdir.

Malignancy is the most important risk factor for venous thromboembolism. Prostate, pancreas and lung cancers are frequently seen with thrombosis. One of the most common causes of the mortality in patients with malignancy is thromboembolism. Moreover, the treatment for thrombosis is also very diffucult for these patients. Here, three lung cancer patients with multiple thrombosis are reported to emphasize the difficulties of thrombosis therapy and the importance of prophylaxis in cancer patients. The treatment has been stopped in three cases because of complications related to thrombosis therapy and the cases were lost.

Abstract | Full Text PDF

1990-2000 yýllarý arasýnda hastanemizde malign plevral mezotelyoma tanýsý konmuþ 92 vaka, klinik ve radyolojik bulgular, taný ve tedavi metodlarý açýsýndan gözden geçirildi. Kýrk dokuzu erkek, 43'ü kadýn olan hastalarýmýzýn ortalama yaþý 56'idi. Temas öyküsü, 1'i erionit, 5'i asbest olmak üzere sadece 6 hastada tespit edildi. Hastalarýmýzýn %65.2'si Marmara Bölgesinden baþvurdu. Vakalarýmýzýn 87'sinde (%94.5) plevra sývýsý mevcuttu. En sýk semptomlar, göðüs aðrýsý (%79.3) ve dispne idi. (%63.04). Semptomlarýn baþlangýcýndan tanýya kadar geçen ortalama süre 5.2 aydý. Çeþitli taný metodlarý ile tespit edilen histolojik tipler epitelyal (%91.5) sarkomatöz (%6.5) ve miks tipti. (%8.6). Taný deðeri, torasentezin %17.2 (14/81), plevra biyopsisinin %57.1 (37/56) VATS'ýn %97.8 (46/47), açýk plevra biyopsisinin %100 (8/8) ve torakoskopinin %100 (11/11) olarak bulundu. Çalýþmamýzda, özellikle torakoskopi,açýk plevra biyopsisi ve VATS'ýn taný deðeri yüksek bulundu. Son yýllarda diðer taný metodlarý ile sonuca ulaþýlamadýðýnda vakit kaybetmeden VATS uygulandýðý ve bu þekilde, semptom baþlangýcýndan tanýya kadar geçen sürenin 4.4 aya indiði ve uygun vakalarda multimodal tedavinin tercih edildiði dikkati çekmektedir.

92 patients diagnosed as malignant mesothelioma at our hospital between 1990 and 2000 are reviewed with respect to clinical and radiological findings, methods of diagnosis and treatment. The median age of 49 male and 43 female patients was 56 years. History of contact could be detected only in 6 patients, in one with erionite and in five with asbestosis. 65.2% of our patients were form the Middle Sea region. Pleural effusion was presents in 87% of cases. The most common symptoms were chest pain (79.3%) and dyspnea (63.04%). The mean time from the start of symptoms until diagnosis was 5.2 months. Histological types obtained by various diagnostic methods were epithelial (81.5%), sarcomatous (6.5%) and mixed type (8.6%) mesotheliomas. Diagnosis was ascertained by thoracentesis in 14 (17.2%), pleural biopsy in 37 (57.1%), VATS in 46 (97.8%), open pleural biopsy in 8 (100%) and by thoracoscopy in 11 (100%) patients. In our study it is pointed out that the diagnostic yield of thoracoscopy, open pleural biopsy and VATS is satisfying. Especially in the recent years, VATS is performed as soon as possible if other diagnostic methods has not yielded a diagnosis. By using VATS the mean time until diagnosis is 4.4 months and multimodality treatment is preferred in selected patients.

Abstract | Full Text PDF

Çalýþmamýzýn amacý, laringeal hipoksi ve hiperokside, solunum ritminde oluþan deðiþikliklerin merkezsel veya periferik kaynaklý olup olmadýðýný araþtýrmaktýr. Deneylerimizde, Na-tiyopentan ile anestezi uygulanan (25 mg/kg-L i.v.) ve hava soluyan tavþanlar kullanýldý. Larinks orofaringeal boþluktan ve trakeadan ayrýldý. Aþaðý trakeal kanül aracýlýðý ile soluk hacmi (VT), soluk frekansý (f/dk) poligrafta kaydedildi ve solunum dakika hacmi (VE) hesaplandý. Sað frenik sinir potansiyellerinden inspirasyon (TI), ekspirasyon (TE) süreleri, ortalama inspiratuar akým hýzý (VT/TI) hesaplandý. Ayrýca sistemik arter kan basýncý kaydedildi. Her bir fazda alýnan arteriyal kan örneklerinde PaO2, PaCO2 ve pH tayin edildi.Deneysel olarak izole edilmiþ laringeal hava yolundan pompa aracýlýðý ile 500 mL/dak akým hýzýnda hava, hipoksi (%7O2-%93N2) ve hiperoksi (%100O2) geçirildi. Hipoksik gazýn geçirilmesinde VT artmýþ, f/dak artýþýna baðlý olarak TI ve TE anlamlý olarak kýsalmýþtýr. VT/TI anlamlý olarak artmýþtýr.Hiperoksik gazýn geçirilmesinde, VT artmýþ, f/dak'daki azalma ile beraber TI ve TE anlamlý olarak uzamýþtýr. Vagotomiyi takiben, superior laringeal sinirlerin kesilmesi VT'deki cevaplarý tamamen ortadan kaldýrmýþtýr. Sonuç olarak bulgularýmýz, hipoksi ve hiperoksinin laringeal mekanoreseptörleri etkileyerek solunum merkezlerinin aktivasyonunu arttýrdýðýný göstermiþtir.

The purpose of this study was to investigate whether the changes in the respiratory pattern during laryngeal hypoxia or hyperoxia have central or peripheric origin. The experiments were carred out in spontaneously air breathing rabbits, anesthetised with soium thiopentane (25mg/kg iv). The larynx was separated from the oropharyngel cavity and from the trachea. Tidal volume (VT), respiratory frequency (f/min) were recorded from the lower tracheal cannula. Minute ventilation (VE) was calculated. Phrenic action potentials were recorded and inspiratory (TI) and expiratory (TE) durations, mean inspiratory flow rate (VT/TI) were determined. Systemic arterial blood pressure was also recorded. At the end of each experimental phase PaO2, PaCO2 and pHa were determined from the blood samples drawn from the left femoral artery. The larynx was insufflated at a flow rate of 500ml/min in hypoxia (7% O2-93% N2) and in hyperoxia (100% O2) by means of the respiratory pump. Insufflation of the larynx with hypoxic gas mixture increased VT, f/min and VE. TI and TE decreased , VT/TI increased significantly. During the insufflation of larynx with hyperoxia VT, VE, TI and TE increased significantly. Following bilateral cervical vagotomy, the responses of f/min, TI and TE to hypoxia and hyperoxia abolished. After cutting the superior laryngeal nerve, the responses of VT to both gas mixtures abolished. In conlusion, the results of this study propose that the stimulation of the laryngeal mechanoreceptors by the effects of hypoxia and hyperoxia increase the activation of the respiratory centers.

Abstract | Full Text PDF

Torasik nörojenik tümörlerin % 60'ý sinir kýlýfýndan kaynaklanmaktadýr. Bu tümörlerin büyük çoðunluðunu benign schwannomalar ile nörofibromlar oluþturmaktadýr. Malign schwannomalar (MSh) ise sýklýkla ekstremiteler ile paravertebral alanlarda yerleþirler. Göðüs duvarýndan MSh geliþimi nadirdir. Altmýþ beþ yaþýnda bayan hasta, hastaneye 4 aydýr devam eden göðüs aðrýsý ve göðüs duvarýnda hýzlý büyüyen kitle nedeniyle baþvurdu. Fizik incelemede saðda orta koltuk altý çizgisi ile arka koltuk altý çizgisi arasýnda lokalize, sert, immobil, aðrýsýz kitle saptandý. Toraksýn bilgisayarlý tomografisinde (TBT) ve MRI incelemesinde ekstraplevral yerleþimli komþu kostalarý destrükte eden yumuþak doku lezyonu ve sað orta lobda bir nodül tespit edildi. Kitlenin malign radyolojik özellikleri nedeniyle, hastaya toraks duvarý rezeksiyonu yapýldý. Kitlenin ve eksize edilen nodülün histopatolojik incelemesiyle olguya MSh tanýsý konuldu. Göðüs duvarýndan köken alan MSh'nýn nadir görülmesi nedeniyle bu olguyu sunmayý uygun bulduk.

60% of the thoracic neurogenic tumors originate from the nerve sheath. The majority of these tumors consist of benign schwannoma and neurofibroma. Malignant schwannomas (MSh) usually settle in the extremities and paravertebral sites. MSh that originate from the chest wall are rare. A 65-years-old woman admitted to the hospital with a 4-month history of thoracic pain and a chest wall mass that rapidly grows. In physical examination a stiff, immobile and painful mass localized on the right thorax between the middle underarm line and the back underarm line was discovered. Both thoracic computerized tomography (CT) and magnetic resonance imaging (MRI) revealed a soft tissue lesion that settled in the extrapleural space and showed destruction in the neighbour ribs and an accompanying nodule in the right middle lobe. Because of the malignant radiological features of the mass, chest wall resection was performed. The diagnosis of MSh was revealed by histological examination of the excised mass and nodule. This case is presented here because of the rarity of MSh originating from the chest wall.

Abstract | Full Text PDF

Pulmoner eozinofilik granüloma (PEG), akciðerlerde Langerhans histiositleri proliferasyonu ile karakterize nadir görülen interstisyel bir akciðer hastalýðýdýr. Akciðerlerde özellikle üst ve orta zonlarý tutan kistik imajlar içerebilen nodüler infiltrasyonla seyreder. Nadiren kemiklerde soliter kistik lezyonlar ve diabetes insipitüsle kendini gösteren santral sinir sistemi tutulumu izlenebilir. Etiyolojisi kesin olarak bilinmemekle beraber sigara içimi ile yakýn iliþkilidir ve %97'ye varan oranlarda sigara içenlerde görülmektedir. Son yýllarda PEG'da sigaraya baðlý bombesin like peptit ve tobakoglikoproteinin immun sistem üzerinde deðiþikliklere yol açarak etiyolojide rol oynadýðý düþünülmektedir. Hastalýðýn klinik seyri deðiþkendir, özellikle sigarayý býrakan olgularda spontan regresyonlar bildirilmiþtir. Kuru öksürük ve sýrt aðrýsý yakýnmalarý ile baþvuran 23 yaþýnda erkek olguda, radyolojik olarak bilateral üst ve orta zonlarda kistik lezyonlar içeren multipl noduler lezyonlar izlendi. Açýk akciðer biyopsisi ile PEG tanýsý alan ve 5. ay itibaren lezyonlarýnda spontan regresyon izlenen olgu sunuldu.

Pulmonary eosinophilic granuloma (PEG) is an uncommon disease of pulmonary interstitium characterized by the proliferation of Langerhans histiocytes. It presents with nodular infiltrations which may have cystic parts most prominent in the middle and upper lung zones. Rarely solid cystic lesions in the bones may be seen and central nervous system may be affected presenting as diabetes incipidus. Although the etiology of the disease is not definitely known, it has close relation with smoking status and it is seen in about 97% in smokers. In the recent years it is thought that bombesin-like-peptid and tobacoglicoprotein attributed to cigarette play a role in etiology by affecting the immune system. Clinical course of the disease is variable, spontaneous remission has been especially reported after smoking cessation. 23-years-old male patient presented with dry cough and chest pain. In his chest X-ray there were multiple nodular lesions with cystic parts in both upper and middle lung fields. The patient who was diagnosed as PEG with an open lung biopsy and showed spontaneous remission in his lesions after the fifth month is presented here.

Abstract | Full Text PDF

Abstract | Full Text PDF