Forty patients with severe chronic stable airflow obstruction and hyperinflation were studied to assess patterns of abnormal chest wall motion and their frequency. Dimensional changes were measured during tidal breathing, four pairs of magnetometers being used to record anteroposterior diameters of ribcage and abdomen and two lateral diameters of the ribcage. Chest wall movements were qualitatively normal in only five patients. Three main types of abnormality were found and 13 subjects had two or more abnormal patterns. Lateral ribcage paradox was present in 31 of the 40 patients and was recognised clinically in all except one. Inspiratory indrawing of the lower sternum was recorded in 12 patients, paradoxical inspiratory motion of the abdomen was present in four patients and in six there was a biphasic expiratory pattern of abdominal movement. Analysis of variance showed no significant group differences in severity of airflow obstruction or hyperinflation between the patients with qualitatively normal motion and those with different types of abnormal motion. Relationships between the tidal displacement of each dimension and severity of airflow obstruction and hyperinflation were examined. In general, patients with more severe hyperinflation showed less abdominal movement and those with more severe airflow obstruction had less lateral expansion of the ribcage, but the correlations were weak. It is concluded that abnormal motion of the chest wall is very common in patients with airflow obstruction and hyperinflation, that clinical recognition of abnormal motion other than lateral ribcage paradox is easily overlooked, and that quantitative relationships between abnormal motion and disease severity are weak.In the normal person during tidal breathing the chest wall expands by displacement of the ribcage and abdomen and this motion is closely related to change in lung volume. In patients with chronic airflow obstruction and hyperinflation various abnormalities of chest wall motion have been reported; the most familiar is paradoxical inspiratory indrawing of the lateral rib margin, which is a well established physical sign of airways obstruction.' 2 Other abnormalities which have been described include paradoxical or incoordinate abdominal motion34 and paradoxical inspiratory indrawing of the ribcage in the anteroposterior dimension;5 these latter abnormalities have been

Of 184 patients, 87 were subsequently found to have intrathoracic malignancy, 93 were found to have benign lung disease and four were lost to follow-up.CYFRA 21.1 was the most efficient marker in differentiating benign from malignant disease, with a sensitivity of 54% and a positive predictive value of 96%. Thirty seven patients who had a negative bronchoscopy subsequently turned out to have malignant disease. Either CYFRA 21.1 or CEA was elevated in 26 (70%) of such patients. Multivariate analysis showed that only CYFRA 21.1 and CEA contributed significantly to the discriminatory power of the data.We conclude that measurement of cytokeratin fragment detected by antibodies BM 19-21 and KS 19-1 and carcinoembryonic antigen at the time of bronchoscopy significantly increased the diagnostic yield in this population and was especially useful in those patients in whom tumour biopsy was not possible at bronchoscopy.

The effects of pneumothorax or pleural effusion on respiratory function as measured by the commonly applied tests were investigated by studying 13 patients (six with pneumothorax, seven with effusion) with and, as far as possible, without air or fluid in the pleural cavity. Measurements included spirometric volumes, carbon monoxide transfer factor (TLco), and Kco by the single breath method, maximum expiratory flow-volume curves, and subdivisions of lung volume estimated by both inert gas dilution and body plethysmography. In patients with pneumothorax "pleural volume" was estimated as the difference between lung volumes measured by dilution and thoracic gas volume measured by plethysmography. In patients with effusion the change in "pleural volume" was equated with the volume of fluid subsequently aspirated."Total thoracic capacity" (TIC) was estimated by adding total lung capacity (TLC) measured by dilution and "pleural volume." Both effusion and pneumothorax produced a restrictive ventilatory defect with reductions of vital capacity, functional residual capacity, and TLC. In the patients with effusion T[C fell after aspiration, suggesting that the pleural fluid produced relative expansion of the chest wall as well as compression of the lung. In patients with pneumothorax, however, there was no difference in TIC with and without air in the pleural space. In the presence of pleural air or fluid there was a slight decrease in TLco and increase in Kco, with a small but significant increase in the rate of lung emptying during forced expiration. With pneumothorax the effects should be more predictable as the pressure in the ipsilateral pleural space is uniform, provided that there is free communication around the lung. The effects of a pleural effusion on the lung and chest wall volumes are less certain as they are likely to be influenced by both the pleural liquid pressure (at the level of the effusion) and the pleural surface pressure (above the pleural effusion).We have examined two groups of patients, one with pneumothorax and the other with pleural effusion, to study the effects of each on the results of the commonly applied tests of pulmonary function. MethodsWe studied six patients with pneumothorax (table 1). In three of these, measurements were made in the presence of a spontaneous pneumothorax and after complete resolution one to three weeks later.The other three patients with pneumothorax had small peripheral bronchial carcinomas and were 60 on 12 May 2018 by guest. Protected by copyright.

Background: Deciding what risks to disclose before a procedure is often challenging for clinicians. Consecutive patients undergoing elective fibreoptic bronchoscopy were randomised to receive simple or more detailed written information about the risks of the procedure and the effects on anxiety and satisfaction levels were compared. Methods: A 100 mm anxiety visual analogue scale (VAS) and a modified Amsterdam preoperative anxiety (scored 4-20) scale (APAIS) were completed before and after reading the designated information leaflet. Following bronchoscopy, subjects completed a satisfaction questionnaire. Results: Of 142 consecutive patients, 122 (86%) (mean age 57.8 years, 53% male) completed the study. Baseline demographic, clinical and anxiety measures were similar in the two groups. Those who received more detailed risk information had significantly greater increase in anxiety levels than those who received simple information on both the VAS (mean 14.0 (95% CI 10.1 to 17.9) vs 2.5 (95% CI 21.4 to 6.4), p,0.001) and the APAIS (1.73 (95% CI 1.19 to 2.26) vs 0.57 (95% CI 0.05 to 1.10), p,0.001). Almost twice as many of those receiving detailed risk information reported that they felt they had received too much information about complications or that the information they had received about bronchoscopy had been worrying. Conclusions: Provision of more detailed risk information before bronchoscopy may come at the cost of a small but significant increase in anxiety.

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Videoscopic debridement of empyema produces excellent results, with minimal patient morbidity and a short hospital stay. We recommend it as the preferred method for first-line management of fibropurulent (stage II) empyema.

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