• Journal of Chest Surgery
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• v.41 no.5
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• pp.619-624
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• 2008

Background: Secondary spontaneous pneumothorax is caused by various underlying lung diseases, and this is despite that primary spontaneous pneumotherax is caused by rupture of subpleural blebs. The treatment algorithm for secondary pneumothorax is different from that for primary pneumothorax. We studied the recurrence rate, the characteristics of recurrence and the treatment outcomes of the patients with secondary spontaneous pneumothorax. Material and Method: Between March 2005 to March 2007, 85 patients were treated for their first episodes of secondary spontaneous pneumothorax. We analyzed the characteristics and factors for recurrence of secondary spontaneous pneumothorax by conducting a retrospective review of the medical records. Result: The most common underlying lung disease was pulmonary tuberculosis (49.4%), and the second was chronic obstructive lung disease (27.6%), The recurrence rate was 47.1% (40/85). The second and third recurrence rates were 10.9% and 3.5%, respectively. The mean follow up period was $21.1{\pm}6.7$ months (range: $0{\sim}36$ month). For the recurrence cases, 70.5% of them occurred within a year after the first episode. The success rates according to the treatment modalities were thoracostomy 47.6%, chemical pleurodesis 74.4%, blob resection 71% and Heimlich valve application 50%. Chemical pleurodesis through the chest tube was the most effective method of treatment. The factor that was most predictive of recurrence was 'an air-leak of 7 days or more' at the first episode. (p=0.002) Conclusion: The patients who have a prolonged air-leak at the first episode of pneumothorax tend to have a higher incidence of recurrence. Further studies with more patients are necessary to determine the standard treatment protocol for secondary spontaneous pneumothorax.

• Tuberculosis and Respiratory Diseases
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• v.42 no.1
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• pp.67-75
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• 1995

Background: Although we gain new knowledge, the problem of pneumonia will not be eliminated. We should understand who is at risk, why these people develop this problem, what causes the pneumonia, and how to manage and prevent respiratory infection. To clarify the alterations of the etiologies of bacterial pneumonia we analysed the recent causative organisms and evaluated the therapeutic implications. Methods: A retrospective four-year study of bacterial pneumonia was conducted in Soon Chun Hyang University Hospital. 190 episodes of bacterial pneumonia was investigated. Results: 1) The causative organisms were isolated in 173 cases on the sputum culture: 154 cases (89%) were gram negative bacilli and 19 cases(11%) were gram positive cocci. The major organisms were Pseudomonas species 49 cases(28%), Klebsiella pneumoniae 29 cases(17%), Enterobacter species 25 cases(14%), and Acinetobacter species 20 cases(12%) in decreasing order. Pseudomonas species(13 cases, 34%) were frequently found in nosocomial pneumonia. 2) The causative organisms were isolated in 16 cases on the blood culture: 7 cases(43%) were gram negative bacilli and 9 cases(57%) were gram positive cocci. The major organisms were Staphylococcus aureus(6 cases, 38%), Pseudomonas species(3 cases, 19%) in decreasing order. 3) In the susceptibility test of causative organisms to antimicrobial drugs, Pseudomonas was susceptible to amikacin, ciprofloxacin, aztreonam, ceftazidime(more than 50%) and resistant to piperacillin, gentamicin, carbenicillin(more than 60%). Klebsiella was susceptible to chloramphenicol, gentamicin, cefotetan(more than 70%) and resistant to carbenicillin, ampicillin(more than 70%). Staphylococcus was susceptible to methicillin(64%), and Streptococcus pneumoniae was susceptible to oxacillin(94%). 4) The response rate after antibiotics therapy was 81% and the mortality rate was 19%. Conclusion: As considering the changes of causative organisms and antibiotic resistance, it behooves us to exercise caution in dispending antibiotics in order to maximize their continued efficacy and to do appropiate antibiotics therapy based on cultures and susceptibility test.

• Tuberculosis and Respiratory Diseases
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• v.40 no.3
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• pp.283-291
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• 1993

Background: Long-term low flow oxygen therapy not only increases survival, but also improves the quality of life in patients with chronic obstructive pulmonary disease (COPD) with chronic hypoxemia. For the assessment and improvement of the status of home oxygen therapy, we analyzed clinical experience of 26 patients who have been administered low flow oxygen at home. Method: Twenty-six patients (18 men and 8 women) who have been received long-term oxygen therapy (LTOT) at home were examined. We reviewed physical characteristics, clinical history, pulmonary function test, ECG, arterial blood gas analysis, hemoglobin and hematocrit, types of oxygen devices, inhalation time per day, concentration of administered $O_2$, duration of $O_2$ therapy, and problems in the home oxygen therapy. Results: The underlying diseases of patients were COPD 14 cases, far advanced old pulmonary tuberculosis 9 cases, bronchiectasis 2 cases, and idiopathic pulmonary fibrosis 1 case. The reasons for LTOT at home were noted for cor pulmonale 21 cases, for dyspnea on exertion and severe ventilatory impairment 4 cases, and for oxygen desaturation during sleep 1 case. The mean values of aterial blood gas analysis before home oxygen therapy were $PaO_2$ 57.7 mmHg, $PaCO_2$ 48.2 mmHg, and $SaO_2$ 87.7%. And the mean values of each parameters in the pulmonary function test were VC 2.05 L, $FEV_1$ 0.92 L, and $FEV_1$/FVC% 51.9%. Nineteen patients have used oxygen tanks as oxygen devices, 1 patient oxygen concentrator, 2 patients oxygen tank and liquid oxygen, and other 4 patients oxygen tank together with portable oxygen. The duration of oxygen therapy was below 1 year in 3 cases, 1~2 years in 15 cases, 3~5 years in 6 cases, 9 years in 1 case, and 10 years in 1 case. All patients have inhalated oxygen with flow rate less than 2.5 L/min. And only 10 patients have inhalated oxygen more than 15 hours per day, but most of them short time per day. Conclusion: For the effective oxygen administration, it is necessary that education for long-term low flow oxygen therapy to patients, their family and neighbor should be done, and also the institutional backup for getting convenient oxygen devices is required.

• Tuberculosis and Respiratory Diseases
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• v.44 no.5
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• pp.1072-1082
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• 1997

Background : To characterize the clinical features and determine the prognostic factors of severe community-acquired pneumonia. This study is the first of its kind in Korea. Methods : Recruited were 40 patients diagnosed as severe community-acquired pneumonia in Hallym University Hospital from January 1, 1989 through July 31, 1996. Patients were analysed retrospectively for age, sex, underlying disease, respiration rate, hypoxemia, requirement of mechanical ventilation, involvement on chest radiograph, shock, and the serum concentration of BUN and albumin. All parameters were compared between survived and dead group. Results : Male to female ratio was 2.07 : 1. The mean age was $63.1{\pm}17.5$years(range 25~90years) with 65% of patients aged equal to or more than 60. The major underlying diseases were old pulmonary tuberculosis(12.5%), chronic obstructive pulmonary disease(7.5%), bronchial asthma(5%), bronchiectasis(2.5%), and diabetes mellitus(22.5%). Microbiologic diagnosis was made in 26 out of 40 patients(65%). The most common causative organism was S. pneumoniae(17.5%, 7/40) followed by S. aureus(15.0%, 6/40), K. Pneumoniae(12.5%, 5/40), M. tuberculosis(7.5%, 3/40), H. influenzae(2.5%, 1/40), coagulase negative staphylococcus(2.5%, 1/40), P. aeruginosa(2.5%. 1/40), E. cloaceae(2.5%, 1/40), and E. coli(2.5%, 1/40). M. pneumoniae was detected in no patient. The most frequent drugs administered in single or combination therapy were aminoglycosides(75%, 30/40), second- and third-generation cephalosporin(40%, 16/40 and 27.5%, 11/40), macrolides(27.5%, 11/40), and amoxicillin/clavulanic acid(22.5%, 9/40). Of the 40 patients, 14 died of severe community-acquired pneumonia(37.5%). Among them, seven patients (50%) expired within 72h of hospital arrival. According to multivariate analysis, mortality was significantly associated with requirement of mechanical ventilation, bilateral pulmonary involvement, and serum albumins$\leq$3.0g/dl. Conclusion : An understanding of the clinical characteristics and prognostic factors in severe community-acquired pneumonia identified in this study will optimize therapeutic approach in this disease and help decreasing its notorious mortality rate.

• Tuberculosis and Respiratory Diseases
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• v.60 no.6
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• pp.663-672
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• 2006

Background: $PM_{10}$(Particulate matter with a diameter ($<10{\mu}m$), which is characterized by different environmental conditions, is a complex mixture of organic and inorganic compounds. The Asian dust event caused by meteorological phenomena can also produce unique particulate matter in affected areas. This study investigated the cytokine produced by A549 epithelial cells exposed to particles collected during both the Asian dust pfenomenon and ambient air particles in a non-dusty period. Method: Air samples were collected using a high volume air sampler(Sibata Model HV500F) with an air flow at $500{\ell}/min$ for at least 6 hours. The cytokine messenger RNA(mRNA) was measured using a reverse transcriptase polymerase chain reaction(RT-PCR). The A549 cells were exposed to 10 to $500{\mu}g/m{\ell}$ of a suspension containing $PM_{10}$ for 24 hours. Each was compared with those in the non-exposed control cells. Result: The mRNA levels of interleukin(IL)-$1{\alpha}$, $IL-I{\beta}$, IL-8, and the granulocyte macrophage colony stimulating factor(GM-CSF) increased after veing exposed to $PM_{10}$ in the ambient air particles, compared with those in the non-exposed control cells. The increase in $IL-1{\alpha}$ and IL-8 were dose dependent at a $PM_{10}$ concentration between $100{\mu}g/m{\ell}$ and $500{\mu}g/m{\ell}$. The mRNA level of IL-8 in the A549 epithelial cells was higher during the in the Asian dust period($500{\mu}g/m{\ell}$) than during the non dust period. Conclusion: A549 cells exposed to the $PM_{10}$ collected during the Asian dust period produce more proinflammatory cytokine than during non-dusty period. This cytokine enhances the local inflammatory response in the airways and can also contribute to the systemic component of this inflammatory process.

• Tuberculosis and Respiratory Diseases
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• v.44 no.4
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• pp.907-913
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• 1997

Background : Congenital bronchoesophageal fistula(BEF) presented in adult life is a rare disorder and has characteristic clinical findings such as paroxysmal cough after water ingestion and recurrent respiratory infections. It usually manifested recurrent pneumonia and chronic cough with purulent phlegmon which was mis-or under-diagnosed as chronic bronchitis, bronchiectasis or lung abscess so forth. Methods : We reviewed retrospectively 13 cases of congenital BEF in adult of Paik Hospital, College of Medicine, Inje University including 22 cases of congenital BEF previously reported in literature of Korea from 1979 through 1995. Results : The mean age at diagnosis was $40.2{\pm}14.3$. There was no difference in sex ratio(Male : Female 18 : 17). The most common symptom was cough(91.4%), followed by chronic sputum(74.3), hemoptysis(25.7), and paroxysmal nocturnal cough at specific position(20%). Twenty one of 31 patients who were able to review have the most specific sign, Ono's sign presented as paroxysmal cough after liquid ingestion. By classification of Braimbridge-Keith, Fourteen(45.1%) of 31 patients were group I (associated with esophageal diverticulum), 15(48.4%) were group II (simple fistula), and group Ill and IV was one case in each. The opening of fistula confined to right lower lobe in 26(76.5%), left lower lobe in 6(17.6%), and left main bronchus in 2(5.9%) cases. Conclusion : Congenital bronchoesophageal fistula is uncommon disorder which has characteristic histories and specific symptoms such as chronic and recurrent lower respiratory infections, and paroxysmal cough after liquid ingestion. Medical attention and careful history should be done in patients who have localized recurrent lower respiratory infections in right lower lobe.

• Tuberculosis and Respiratory Diseases
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• v.43 no.5
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• pp.736-745
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• 1996

Background : It is known that pulmonary rehabilitation improves dyspnea and exercise tolerance in patient with chronic lung disease, although it does not improve pulmonary function. But there is a controversy whether this improvement after pulmonary rehabilitation is due to increased aerobic exercise capacity. We performed this study to evaluate the effect of pulmonary rehabilitation for 6 weeks on the pulmonary function, gas exchange, exercise tolerance and aerobic exercise capacity in patients with chronic lung disease. Methods : Pulmonary rehabilitations including education, muscle strengthening exercise and symptom-Umited aerobic exercise for six weeks, were performed in fourteen patients with chronic lung disease (COPD 11, bronchiectasis 1, IPF 1, sarcoidosis 1 ; mean age $57{\pm}4$ years; male 12, female 2). Pre- and post-rehabilitaion pulmonary function and exercise capacity were compared. Results: 1) Before the rehabilitation, FVC, $FEV_1$ and $FEF_{25-75%}$ of the patients were $71.5{\pm}6.4%$. $40.6{\pm}3.4%$ and $19.3{\pm}3.8%$ of predicted value respectively. TLC, FRC and RV were $130.3{\pm}9.3%$, $157.3{\pm}13.2%$ and $211.1{\pm}23.9%$ predicted respectively. Diffusing capacity and MVV were $59.1{\pm}1.1%$ and $48.6{\pm}6.2%$. These pulmonary functions did not change after pulmonary rehabilitation. 2) In the incremental exercise test using bicycle ergometer, maximum work rale ($57.7{\pm}4.9$) watts vs. $64.8{\pm}6.0$ watts, P=0.036), maximum oxygen consumption ($0.81{\pm}0.07$ L/min vs. $0.96{\mu}0.08$ L/min, P=0.009) and anaerobic threshold ($0.60{\pm}0.06$ L/min vs. $0.76{\mu}0.06$ L/min, P=0.009) were significantly increased after pulmonary rehabilitation. There was no improvement in gas exchange after rehabilitation. 3) Exercise endurances of upper ($4.5{\pm}0.7$ joule vs. $14.8{\pm}2.4$ joule, P<0.001) and lower extremity ($25.4{\pm}5.7$ joule vs. $42.6{\pm}7.7$ joule, P<0.001), and 6 minute walking distance ($392{\pm}35$ meter vs. $459{\pm}33$ meter, P<0.001) were significantly increased after rehabilitation. Maximum inspiratory pressure was also increased after rehabilitation ($68.5{\pm}5.4$ $CmH_2O$ VS. $80.4{\pm}6.4$ $CmH_2O$, P<0.001). Conclusion: The pulmonary rehabilitation for 6 weeks can improve exercise performance in patients with chronic lung disease.

• Journal of Chest Surgery
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• v.30 no.12
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• pp.1225-1231
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• 1997

Spontaneous pneumothorax is the sudden collapse of a lung usually caused by air leakage from a subvisceral pleural blob. Responses to closed thoracostomy,thoracentesls and simple observation are usually prompt and effective. But in some cases, these are unsucceful and open thoracotomy is indicated. A clinical evaluation was performed on 242 cases(236 patients) of open thoracotomy in spontaneous pneumoth rax who were admitted and treated at department of Thoracic and Cardiovascular Surgery. Masan Samsung General Hospital during the past 9 years from January 1988 to December 1996. The results were as follows 1. The sex ratio was male predominance(M:F=11.7:1) 2. The most common age group were 2nd, 3rd decades(2nd=29.3%, 3rd=30.2%). 3. The most common chief complaints were chest pain and dyspnea(chest pain=41.7%. dryspnea= 36.8). 4. The etiologic factors of spontaneous pneumothorax were primary spontaneous pneumothorax(86.4%), tuberculosis(9.1%), COPD(3.7%) and pleuritis(0.8%). 5. The site of spontaneous pneumothorax was 52.1% in right, 45.4% in left and 2.5% in both. 6. The common indications of open thoracotomy were recurrence(44.2%), persistent air leakage(31.8%) and inadequate expansion(15.7%). 7. The operative procedures were bullectomy or mechanical pleurodesis through posterolateral thoracotomy or median sternotomy. 8. The most frequent location of bulla or blob were apical segme t oi RUL(35.1%) and apicoposterior segment of LUL(41.3 %). 9. The number of bulla or blob were mainly 1 to 5(88%), and there were no significant differences among operation indications. 10. The size of bulla or bleb were mainly below 5cm(81%)and small bulla($\leq$1cm) were predominant in recurrence group but large bulla(>5cm)were predominant in persistent air leakage and inadequate expansion group. 11. The pleural adhesion was seen in 54.5%.(Recurrence group 64.1%,Persistent air leakage group 51.9%,Inadequate expansion group 47.4%).

• Tuberculosis and Respiratory Diseases
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• v.42 no.3
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• pp.361-369
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• 1995

Background: A number of different weaning techniques can be employed such as spontaneous breathing trial, Intermittent mandatory ventilation(IMV) or Pressure support ventilation(PSV). However, the conclusive data indicating the superiority of one technique over another have not been published. Usually, a conventional spontaneous breathing trial is undertaken by supplying humidified $O_2$ through T-shaped adaptor connected to endotracheal tube or tracheostomy tube. In Korea, T-tube trial is not popular because the high-flow oxygen system is not always available. Also, the timing of extubation is not conclusive and depends on clinical experiences. It is known that to withdraw the endotracheal tube after weaning is far better than to go through any period. The tube produces varying degrees of resistance depending on its internal diameter and the flow rates encountered. The purpose of present study is to evaluate the effectiveness of weaning and extubation following a 60 minutes spontaneous breathing trial with simple oxygen supply through the endotracheal tube. Methods: We analyzed the result of weaning and extubation following a 60 minutes spontaneous breathing trial with simple oxygen supply through the endotracheal tube in 18 subjects from June, 1993 to June, 1994. They consisted of 9 males and 9 females. The duration of mechanical ventilation was from 38 hours to 341 hours(mean: $105.9{\pm}83.4$ hours). In all cases, the cause of ventilator dependency should be identified and precipitating factors should be corrected. The weaning trial was done when the patient became alert and arterial $O_2$ tension was adequate($PaO_2$ > 55mmHg) with an inspired oxygen fraction of 40%. We conducted a careful physical examination when the patient was breathing spontaneously through the endotracheal tube. Failure of weaning trial was signaled by cyanosis, sweating, paradoxical respiration, intercostal recession. Weaning failure was defined as the need for mechanical ventilation within 48 hours. Results: In 19 weaning trials of 18 patients, successful weaning and extubation was possible in 16/19(84.2 %). During the trial of spontaneous breathing for 60 minutes through the endotracheal tube, the patients who could wean developed slight increase in respiratory rates but significant changes of arterial blood gas values were not noted. But, the patients who failed weaning trial showed the marked increase in respiratory rates without significant changes of arterial blood gas values. Conclusion: The result of present study indicates that weaning from mechanical ventilation following a 60 minutes spontaneous breathing with $O_2$ supply through the endotracheal tube is a simple and effective method. Extubation can be done at the same time of successful weaning except for endobronchial toilet or airway protection.

• Journal of Chest Surgery
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• v.41 no.1
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• pp.34-40
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• 2008

Background: Off-pump coronary artery bypass grafting (OPCAB) shows fewer side effects than cardiopulmonary by. pass, and other benefits include myocardial protection, pulmonary and renal protection, coagulation, inflammation, and cognitive function. We analyzed the clinical results of our cases of OPCAB. Material and Method: From May 1999 to August 2007, OPCAB was performed in 100 patients out of a total of 310 coronary artery bypass surgeries. There were 63 males and 37 females, from 29 to 82 years old, with a mean age of $62{\pm}10$ years. The preoperative diagnoses were unstable angina in 77 cases, stable angina in 16, and acute myocardial infarction in 7. The associated diseases were hypertension in 48 cases, diabetes in 42, chronic renal failure in 10, carotid artery disease in 6, and chronic obstructive pulmonary disease in 5. The preoperative cardiac ejection fraction ranged from 26% to 74% (mean $56.7{\pm}11.6%$). Preoperative angiograms showed three-vessel disease in 47 cases, two-vessel disease in 25, one-vessel disease in 24, and left main disease in 23. The internal thoracic artery was harvested by the pedicled technique through a median sternotomy in 97 cases. The radial artery and greater saphenous vein were harvested in 70 and 45 cases, respectively (endoscopic harvest in 53 and 41 cases, respectively). Result: The mean number of grafts was $2.7{\pm}1.2$ per patient, with grafts sourced from the unilateral internal thoracic artery in 95 (95%) cases, the radial artery in 62, the greater saphenous vein in 39, and the bilateral internal thoracic artery in 2. Sequential anastomoses were performed in 46 cases. The anastomosed vessels were the left anterior descending artery in 97 cases, the obtuse marginal branch in 63, the diagonal branch in 53, the right coronary artery in 30, the intermediate branch in 11, the posterior descending artery in 9 and the posterior lateral branch in 3. The conversion to cardiopulmonary bypass occurred in 4 cases. Graft patency was checked before discharge by coronary angiography or multi-slice coronary CT angiography in 72 cases, with a patency rate of 92.9% (184/198). There was one case of mortality due to sepsis. Postoperative arrhythmias or myocardial in-farctions were not observed. Postoperative complications were a cerebral stroke in 1 case and wound infection in 1. The mean time of respirator care was $20{\pm}35$ hours and the mean duration of stay in the intensive care unit was $68{\pm}47$ hours. The mean amounts of blood transfusion were $4.0{\pm}2.6$ packs/patient. Conclusion: We found good clinical outcomes after OPCAB, and suggest that OPCAB could be used to expand the use of coronary artery bypass grafting.