Flexible bronchoscopy is an important diagnostic technique for study of pediatric patients with pulmonary problems. Many pitfalls await the unwary, but with experience and care, most can be overcome or circumvented.

We conducted retrospective chart and literature reviews to analyze the frequency and spectrum of causes of asymptomatic pleural effusion (APE). In our series, 16 percent of patients undergoing thoracentesis for PE were asymptomatic and the spectrum of causes was similar to that for symptomatic patients. Asymptomatic PEs were evenly distributed among transudates, exudates and indeterminate effusions. More symptomatic (S) PE were exudates, although the difference was not statistically significant (p greater than 0.1). In comparison to SPE, APE were more often free flowing and small. In both groups, the four most common diagnoses were malignancy, CHF, parapneumonic and postoperative effusions accounting for greater than 70 percent of each group. Review of the literature demonstrated the following associations with APE: recent childbirth or abdominal surgery, benign asbestos effusion, uremia, malignancy, and tuberculosis. In the uncomplicated postpartum or postoperative setting or in patients with typical findings of left ventricular failure, observation without diagnostic studies is appropriate. In all other situations, APE should be evaluated in traditional fashion. If thoracentesis is non-diagnostic and the effusion is an exudate, closed pleural biopsy and less often, fiberoptic bronchoscopy, should follow. Once malignant or granulomatous pleuritis has been excluded, it may be appropriate to observe for a period of time before proceeding to more invasive procedures.

Carbon monoxide poisoning is a major cause of illness and death in the United States. Most cases result from exposure to the internal combustion engine and to stoves burning fossil fuels. Most cases of accidental exposure are preventable if proper precautions are taken; however, when cases arise, their presenting signs and symptoms are nonspecific and often lead to a misdiagnosis resembling a flu-like viral illness. As a result, the incidence of acute CO poisoning is underestimated. The effects of CO poisoning are due to tissue hypoxia, with the CNS and the heart being the most susceptible target organs due to their high oxygen needs. Prolonged hypoxia due to high CO levels may lead to cardiac arrhythmias or arrest (or both) and a variety of neurologic sequelae. Treatment is directed toward the relief of tissue hypoxia and the removal of CO from the body. Severity of poisoning can be divided into three levels based on CO levels in the blood. Administration of normobaric 100 percent oxygen is the therapy of choice for most cases, while hyperbaric oxygen therapy is reserved for severe poisonings.

This review has examined the possible role of CMI in providing protection against three pathogens that can be opportunists in the lung. Monoclonal antibodies that identify the cellular components of the immune response and recombinant cytokines are important tools to better understand how pulmonary immunity is regulated. Although not discussed in detail, recombinant microbial antigens are useful for understanding various aspects of protective immunity and immunosuppression as well as for advancing vaccine development. There are important problems to address in order to continue steady progress in understanding pulmonary defenses, including some of those mentioned in this brief review. There should be an increased use of infectious models that more closely mimic naturally occurring infections, and comparisons should be made between results obtained with parenteral versus intrapulmonary routes of infection.

A patient with prior GBF and new-onset hemoptysis was diagnosed as having recurrent GBF by measurement of bronchial secretion pH. This is a previously unreported means of diagnosing this process. Bronchoscopic findings were substantiated by upper GI contrast study and surgical findings.

Recommendations for the prophylaxis of BE have changed over the last 10-15 years toward fewer-dose and oral regimens. An advisory committee of the AHA is currently formulating new guidelines for the prevention of BE that will likely be promulgated in 1990 or 1991. It is anticipated that such recommendations will feature the new information on MVP and focus on oral prophylactic regimens.

The flexible fiberoptic bronchoscope is currently the standard tool for localization of radiographically occult carcinomas of the tracheobronchial tree. It allows direct inspection of proximal airways and can establish the location of most occult lung cancers. A small percentage of patients present with bronchoscopically as well as radiographically occult carcinoma, particularly challenging because definitive localizations is required before a therapeutic plan can be outlined. Selective cytologic brushing of each lobar segment, taking random biopsy specimens, has been used to assist in localization of these early cancers. Recently, fluorescent compounds have been used to assist in localizing early lung cancers and in the treatment of radiographically occult carcinoma. We review the current methods of bronchoscopic localization and treatment of radiographically occult lung cancer.