This study prospectively compared the diagnostic yield of transbronchial biopsies using large and small forceps (cup sizes, 3 x 2 x 0.9 versus 2 x 1.5 x 0.6 mm, respectively). Diagnostic yield was compared by a pathologist, blinded to the size of forceps used on the basis of the relative amount of tissue obtained, alveolar tissue obtained, and ability to ascertain a histopathologic diagnosis. Large forceps obtained significantly more tissue than did small forceps (20 of 27 patients [74%] versus five of 27 patients [19%], p < 0.005, with similar amounts obtained in two patients). Also, large forceps obtained significantly more alveolar tissue than did small forceps (16 of 22 patients [73%] versus six of 22 patients [27%], p < 0.05, with no alveolar tissue obtained in five patients). In 18 of the 27 patients, biopsies performed resulted in nonspecific diagnoses, including fibrosis or chronic inflammation. All nine of the patients with a specific diagnosis were ultimately proved to have sarcoidosis. There was a trend toward more of these patients having noncaseating granulomas obtained with the large forceps than with the small forceps (seven of nine patients versus four of nine patients). No difference was observed in the amount of postbiopsy bleeding with either forceps. We conclude that large forceps used for transbronchial biopsy yield more tissue and more alveolar tissue than do small forceps. These findings may have an impact on the diagnostic yield in some diseases such as sarcoidosis.

Among 240 military personnel evaluated after presenting with postdeployment exertional dyspnea, a combination of symptoms, auscultatory findings, imaging, and visualization of the airways by bronchoscopy identified six individuals with excessive dynamic central airway collapse as the sole apparent cause of dyspnea. Exercise-associated excessive dynamic airway collapse should be considered in the differential diagnosis of exertional dyspnea.

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The records of 335 patients admitted to the general medicine wards and to the medical intensive and coronary care unit (MICCU) at Brooke Army Medical Center were retrospectively reviewed to assess the frequency of advance directives and "do not resuscitate" (DNR) designations. Two hundred sixty-seven (79.7%) were admitted to the ward and 68 (20.3%) were admitted to the MICCU. Advance directives were executed in 14.9% of patients. DNR designations were made for 21 (7.9%) patients on the ward and 11 (16.2%) patients in the MICCU (p = 0.064). There were no statistical differences in mean length of stay, presence of advance directives, or documentation of advance directives in ward versus MICCU patients. However, there was a statistical difference in the number of deaths in the MICCU as compared with that on the ward (9.7 vs. 2.7%, p < 0.05). The frequency of advance directives and DNR designations did not differ between ward and MICCU patients in this population, although there was a trend for greater DNR designations in the MICCU environment.