This retrospective study of elective pneumonectomy for complicated inflammatory lung disease was done to define modern-day mortality and morbidity. One hundred twenty-four patients received elective pneumonectomy. Patient ages ranged from 6 months to 71 years. Past, recurrent, or new pulmonary tuberculosis was present in 107 patients (86.3%). Clinical presentation involved recurrent infections or severe suppurative sequelae (abscess, empyema). Forty-seven patients had chronic hemoptysis and 25 patients had past or recent massive hemoptysis (> 600 ml of hemoptysis fluid within 24 hours). Nutritional deficiencies were common. One hundred six patients (85.5%) had end-stage destroyed lungs. Evaluative bronchoscopy showed inflammatory endobronchial changes in 106 patients (85.5%), bronchial strictures in 4, and indolent endobronchial tumor in 2. Lung separation was by double-lumen tube in 96 patients, single lung-single tube in 6, bronchus blocker in 6, and prone posture in 9. Extrapleural pneumonectomy was done in 83 patients (66.9%). Fifty-seven of these procedures were left sided and 26 were right sided. Standard transpleural pneumonectomy was done in 41 patients (33.1%): 30 left sided and 11 right sided. Nine pneumonectomies were conducted with the patient in the prone position. Four patients had completion pneumonectomy. Hospital mortality was three deaths (2.4%). Morbidity included postpneumonectomy empyema in 19 patients (15.3%). Seven postoperative bronchopleural fistulas occurred. Empyema in most patients was managed by open pleural drainage (thoracostoma) and later space closure. Pneumonectomy proved effective therapy with low mortality but postpneumonectomy empyema posed serious morbidity.

Twelve successive patients with massive haemoptysis were treated by emergency rigid bronchoscopy and lavage of the bleeding lung with cold saline. All patients stopped bleeding during the procedure and all blood and clot was evacuated from the accessible airways. The bleeding source was localised to a lobe in seven cases, and lateralised in the remaining five patients. Two patients had a second haemorrhage during that hospital stay and cold saline lavage again terminated it. Further therapy, either surgical or medical was based on information obtained during the respite from haemorrhage achieved with this technique. There was no hospital mortality in the series.The conservative management of haemoptysis is generally successful, but 10-15% of all patients with rhaemoptysis may bleed to a life-threatening extent.1 2 This figure includes patients with limited pulmonary reserve in whom the spillage of moderate amounts of blood into the tracheobronchial tree causes critical deterioration in lung function, and those in danger of asphyxiation from the sheer volume of blood aspirated. The various methods of management of lifethreatening haemoptysis include drug therapy endoscopic control measures (endobronchial balloon tamponade, topical adrenalin application, and lung isolation with double lumen endotracheal tubes), bronchial artery embolisation techniques, and lung resection. The performance of a pulmonary resection on a patient who is actively bleeding and whose respiratory reserve is unknown is necessarily hazardous. The occurrence of massive haemoptysis in poor risk patients has encouraged the development of nonsurgical methods of management. Our experience with emergency rigid bronchoscopy and cold saline lavage in 12 patients with massive haemoptysis forms the basis of this report. No similar experience has been reported.

Twenty-six AIDS patients were enrolled in an open label pilot study to evaluate the efficacy and toxicity of topical 1 percent ophthalmic trifluridine solution for the treatment of chronic mucocutaneous herpes simplex virus disease unresponsive to at least 10 days of acyclovir therapy. Susceptibility testing to acyclovir, trifluridine, and foscarnet was determined by plaque reduction assay. Twenty-four patients were evaluable for efficacy and 25 for toxicity analyses. Seven patients (29 percent) had complete healing of lesions. The overall estimated median time to complete healing was 7.1 weeks. An additional seven patients had > or = 50 percent reduction in lesion area. The overall estimated median time to 50 percent healing was 2.4 weeks. Ten (42 percent) patients discontinued treatment for reasons other than primary treatment failure and seven (29 percent) for failure to respond to therapy. Baseline patient characteristics associated with greater reduction in lesion area included higher Karnofsky score (p = 0.05), fewer lesions (p = 0.07), smaller lesion area (p = 0.11), and trifluridine susceptibility (p = 0.07). Eight (33 percent) patients developed new lesions outside of the treatment area while on study, reflecting the local nature of this therapy. No dose-limiting toxicity attributable to trifluridine was reported. Given the limited options for the treatment of acyclovir-resistant herpes simplex disease, topical trifluridine may be a useful alternative in selected patients.

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Bronchoscopy demonstrated a whitish tumour mass in the left main stem bronchus which occluded the lumen.The mucosa of the right bronchus just distal to the carina looked irregular. Biopsies were taken of the tumour in the left main bronchus and of the irregular right bronchial mucosa. The histological features of the tumour in the left bronchus showed normal respiratory epithelium without pseudoepitheliomatous hyperplasia. Underlying the epithelial surface were granular cells with small dark nuclei, large fusiform cells with elongated nuclei, and other cells with eosinophilic cytoplasm (fig 2); features compatible with the diagnosis of a granular cell myoblastoma. Histological examination of the specimen from the right main bronchus revealed an infiltrating, moderately well-differentiated squamous carcinoma.The treatment of this patient was problematic. The proximity of the squamous tumour to the carina contraindicated surgical therapy, leaving radiotherapy as the alternative. The myoblastoma could have been removed via a transthoracic bronchotomy, by endobronchial resection, pneumonectomy, or lobectomy.