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INDICATIONS :END-TIDAL CO2 MONITORING

INDICATIONS :END-TIDAL CO2 MONITORING. Validation of proper endotracheal tube placement and maintain position •Evaluation of ventilation-perfusion mismatch :hemodynamic •Adequacy of pulmonary perfusion/Cardiac function and volume status •Evaluate ventilator settings (TV, RR and PEEP)

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INDICATIONS :END-TIDAL CO2 MONITORING

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  1. INDICATIONS :END-TIDAL CO2 MONITORING Validation of proper endotracheal tube placement and maintain position •Evaluation of ventilation-perfusion mismatch :hemodynamic •Adequacy of pulmonary perfusion/Cardiac function and volume status •Evaluate ventilator settings (TV, RR and PEEP) •Detection of obstruction airways : Bronchospasm •Detection of airway leaks or loss airway (transport patient) •CPR (adequacy of compression and detect ROSC/prognosis) [Respir Care 2003;48(5):534–539]

  2. The Utility of Survivin mRNA As A Diagnostic Biomarker in Lung Cancer with Malignant Pleural Effusion GehanH.Abo El-Magd, Ahmad Sh. Mohamed, OmniaAbd El-Fattah & AmalAbdElateef

  3. Dr. Gehan H Abo El-Magd, MD Lecturer of Chest diseases Tanta University

  4. Tanta Faculty of Medicine, Egypt

  5. Pleural Effusion Pleural effusions have a variety of etiologies including: • Malignancies • Pneumonia • Tuberculosis • Pulmonary embolism • Cardiac failure and cirrhosis

  6. The initial diagnostic approach includes thoracocentesis and cytological, histological and biochemical examinations. • Differentiating between malignant pleural effusion (MPE) and non-MPE???? • Only about 50–70% of the patients with pleural malignancies can be diagnosed by the cytological examinations of the pleural fluids.* Oncol Rep. 2004; 12(1): 79-83

  7. Malignant Pleural Effusion (MPE) • The International Association for the Study of Lung Cancer (IASLC) recently undertook revisions that placed pleural dissemination of disease, including MPE, into an M1a classification, making it a stage IV disease

  8. Diagnosis of MPE • Confirming the MPE etiology in the patient with a negative cytological examination requires more complicated diagnostic procedures, such as Needle pleural biopsy or thoracoscopy

  9. Various adjuvant methods have been proposed e.g. specific tumor markers. • Some studies show that the sensitivity, specificity and diagnostic accuracy of different tumor markers are quite low. Chest. 2002; 122:1037–57

  10. Survivin Why?????

  11. Survivin is undetectable in normal differentiated tissues. • Survivin is up-regulated in most cancers, including: lung, breast, esophagus, stomach, colon, pancreas, bladder, uterus, ovary and liver carcinomas, soft tissue sarcomas, and leukemias.

  12. Survivin is an inhibitor of programmed cell death (by suppression of caspases 3 and 7) • Survivin is expressed in the G2-M phase of the cell cycle. • Its interaction with the mitotic spindle apparatus has been reported to be essential for antiapoptotic function.* Biochemistry. 2001; 40: 1117-23

  13. Some studies • A study (2005) reported significantly increased levels of survivin mRNA in pleural malignant mesotheliomas compared to normal/fibrotic pleural tissues. * • In a recent study (2009), survivin protein expression in the malignant pleural effusions was 81.6%, it was significantly higher than that of pleural effusion cytology (52.1%) and benign effusion (8%). *Lung Cancer. 2005; 48: 211–216

  14. Many studies have indicated a correlation between survivin expression and either unfavorable prognosis or a lack of response to chemotherapy in various tumor tissues.

  15. Objective To evaluate diagnostic value of survivin mRNA expression in pleural effusions from lung cancer patients.

  16. Patients and Methods • This work was carried out on 85 patients with pleural effusion attended in Chest and Clinical Oncology Departments, Tanta University Hospital during the period from October 2009 to January 2011. • This study was performed in compliance with ethical rules at our locality.

  17. Patients and Methods • Patients with pleural effusion routinely underwent diagnostic thoracocentesis to obtain pleural fluid specimens for cell count; the measurement of total protein, lactate dehydrogenase (LDH) and cytological examination. • The effusions were classified as benign or malignant according to clinical and pathological diagnoses.

  18. Patients and Methods -- This study included 2 groups • Group I: included 65 pleural fluid specimens were collected from patients with newly diagnosed lung cancer. • Group II: included 20 benign pleural fluid specimens, considered to be control group, and this group was classified into transudate and exudate according to Light’s criteria.

  19. Patients and Methods N.B. • Malignant pleural effusionwas diagnosed if malignant cells were found on cytological examination. • Paramalignant effusions were effusions that are not the direct result of neoplastic involvement of the pleura but related to the primary tumor.

  20. Patients and Methods • RT-PCR was performed to detect the survivin mRNA expression in the pleural fluid specimens. • The results were compared with their cytological examinations. • The sensitivity, specificity and accuracy were calculated by using receiver operating characteristic (ROC) analysis.

  21. RESULTS

  22. Results • Group I (Lung cancer related pleural effusion): • It included 65 patients, 25 (38.46%) females and 40 (61.54%) males. • Only 38/65 (58.46%) had positive cytological examinations. • The positive rate of survivin mRNA expression in maligant pleural effusion (62/65; 95.38%) was much higher than that in the pleural effusion with benign disease (4/20; 20%, P<0.01).

  23. Results • Group II (Benign pleural effusion group): • It included 20 patients, they were 8 females and 12 males, they were classified according to etiology into: • Exudative effusion (group IIA): • 8 (61.54%) patients with TB, 3 (23%) patients with pneumonia, 2 (15.38%) patients with pulmonary embolism. • Transudative effusion (group IIB): • 3 (42.85%) patients with congestive heart failure and 4 (57.14%) patients with liver cirrhosis.

  24. Table (1): Characteristics of patients in the studied groups

  25. Figure (1): ROC curves for survivin expression classification (AUROC curve is 0.731 (73.1 %), p <0.001*) in group I. The plot was constructed by computing the sensitivity vs. (1 ̶ specificity) for the different possible cutoff points of the survivin mRNA.

  26. Results • The sensitivity, specificity and accuracy were 89.5, 50 and 73.1% of survivin for diagnosing MPE and for cytology was 40, 93.7 and 67.8% respectively.

  27. Figure (2): Survivin mRNA expression in group I. Box plot showing expression levels of survivin mRNA in positive and negative pleural effusion cytology above cut off value

  28. Table (4): Correlation between pleural effusion survivin and selected univariate parameters

  29. Conclusions • The detection of survivin by RT-PCR seems to be a promising assay to diagnose malignant pleural effusions. • Using the appropriate cut-off point, survivin mRNA has a significant role in differentiating benign from malignant pleural effusion.

  30. Thank you

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