warfarin and Lung-Diseases

Diagnostic bronchoscopy and tissue sampling techniques using forceps (endobronchial biopsy [EBB] and transbronchial biopsies [TBB]) or needle aspiration (transbronchial needle aspiration-TBNA), all performed with a flexible bronchoscope, are the basic elements of any interventional procedure. The flexible fibrobronchoscopy allows the visualization of the airways and is used both for diagnostic and therapeutic purposes. The working channel of both fibrobronchoscopes with optical fibers and videobronchoscopes, even if of relatively small diameter, allows the insertion of various diagnostic and therapeutic accessories. Fiber optic systems have been widely replaced by video cameras using a miniaturized charge-coupled device camera positioned at the end of the scope that provides electronic transmission of images to a monitor. The indications for both diagnostic and therapeutic fibrobronchoscopy derive from a correct evaluation of symptoms and objective signs of the patient and from the correct interpretation of imaging methods. Although bronchoscopy techniques keep evolving at a rapid pace, basic procedures such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration still play a key role in pulmonary disease diagnostics, and therefore, these methods must still be part of the training of interventional pulmonologists. Trainees will acquire a thorough knowledge of thoracic anatomy and become skilled in the interpretation of thoracic imaging, after which they will be given a theoretical and practical training course on virtual reality simulators, on animal or cadaver models, the effectiveness of which has been fully demonstrated by scientific studies. Specific DOPS tests have been developed for a qualitative evaluation of procedures on simulators, on animal models and on the patient.

Topics: Anticoagulants; Biopsy, Needle; Bronchoscopy; Clinical Competence; Computer Simulation; Endoscopy; Equipment Design; Humans; Lung; Lung Diseases; Lung Diseases, Interstitial; Lung Neoplasms; Optical Fibers; Platelet Aggregation Inhibitors; Pulmonary Medicine; Purinergic P2Y Receptor Antagonists; Video Recording; Warfarin

Patients with cancer, including lung cancer are at an increased risk for venous thromboembolism and frequently are anticoagulated. Due to concerns of bleeding and drug-drug interactions, many clinical trials suggest the use of low-molecular-weight heparin (LMWH) rather than warfarin (coumadin) for patients requiring anticoagulation. We sought to evaluate, in a retrospective analysis, whether these recommendations were appropriate.. A pooled analysis of three lung cancer trials conducted by the NCIC Clinical Trials Group was performed to evaluate the risk of bleeding in patients receiving warfarin or LMWH; concomitant usage of nonsteroidal antinflammatories or aspirin. The Mantel-Haentzel test stratified by treatment group was used to analyze the prevalence of bleeding (all and > or =grade 3) according to LMWH, warfarin or nonsteroidal antiinflammatory drugs usage. Logistic regression was used to adjust for baseline characteristics including age, sex, performance status, creatinine, platelets.. Although bleeding was reported in a quarter of patients, only 2% experienced severe bleeding, with rates similar across the trials. In univariate analyses the risk of bleeding seemed higher with LMWH or warfarin usage, history of bleeding, thrombocytopenia, and increased age. However, in adjusted analyses only warfarin use was a significant risk factor (p = 0.073).. In this retrospective analysis, warfarin seemed to increase the risk of bleeding in lung cancer patients enrolled in clinical trials. Current recommendations in many clinical trials to preferentially use LMWH seem appropriate.

Topics: Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antineoplastic Combined Chemotherapy Protocols; Female; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Lung Diseases; Lung Neoplasms; Male; Prognosis; Randomized Controlled Trials as Topic; Retrospective Studies; Risk Factors; Venous Thromboembolism; Warfarin

A 75-year-old man was admitted to our clinic with the complaints of palpitation, fever, severe dyspnea, dizziness and bloody sputum associated with coughing. Chest radiographs revealed that the lungs were bilaterally infiltrated. A high resolution computed tomographic study of the thorax disclosed diffuse alveolar hemorrhage, of which presence was proved by histopathological study of bronchoalveolar lavage material. The hemorrhage occured at 8th day of 5 mg daily warfarin therapy, which was given for frequent atrial fibrillation attacks was controlled by fresh frozen plasma and vitamin K. Alveolar hemorrhage is difficult to diagnose and has high mortality if the treatment was not started as soon as possible. This is the first report of alveolar hemorrhage caused by 5 mg daily warfarin therapy. We propose that the patient's age, nutritional status, used drugs should be taken into consideration for true management of patients with atrial fibrillation.

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Atrial Fibrillation; Hemorrhage; Humans; International Normalized Ratio; Lung Diseases; Male; Pulmonary Alveoli; Tomography, X-Ray Computed; Vitamin K; Warfarin

Topics: Animals; Anticoagulants; Biopsy; Bronchoscopy; Disease Models, Animal; Hemorrhage; Humans; Iatrogenic Disease; Lung Diseases; Swine; Warfarin

Topics: Anticoagulants; Clinical Trials as Topic; Hemorrhage; Heparin; Humans; Lung Diseases; Pulmonary Embolism; Recurrence; Risk; Thrombophlebitis; Time Factors; Warfarin

BACKGROUND Diffuse alveolar hemorrhage (DAH) caused by direct oral anticoagulants (DOACs) has increased in recent years with the increase in prescriptions of DOACs. Generally, DOACs are considered to have a lower bleeding risk than the traditional anticoagulant, warfarin. However, major bleeding, including DAH, due to DOACs can be seen in clinical practice, and there are few reports to elucidate when DOAC-associated alveolar hemorrhage occurs and whether DOAC-induced DAH has a trigger. CASE REPORT An 80-year-old man diagnosed and treated for atrial fibrillation with apixaban 2.5 mg twice daily for 1 year before admission, underwent 2 invasive medical procedures over a short period of time. Hemoptysis began after the procedures. He experienced shortness of breath and rapidly progressive hypoxic respiratory failure. His postsurgical oxygen saturation level dropped rapidly. Chest radiography and computed tomography images showed pulmonary infiltration and ground-glass opacity in both lungs. Apixaban treatment was discontinued, and mechanical ventilation was initiated. Bronchoalveolar lavage cytology revealed hemosiderin-laden macrophages. A diagnosis of diffuse alveolar hemorrhage (DAH) was made. In previous reports about DAH caused by DOACs, most patients had bleeding triggers; drug interactions in patients taking DOACs are one of such triggers. Although DOACs are relatively safe for elderly patients, DAH can occur in patients receiving either early-stage or long-term treatment. CONCLUSIONS The onset of DOAC-associated DAH is not limited to the early stages of medication initiation. Various triggers can induce DAH in patients receiving DOACs.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Hemorrhage; Humans; Lung Diseases; Male; Pyridones; Respiratory Insufficiency; Stroke; Warfarin

Warfarin is one of the most frequently used anticoagulant agents in the clinic. The most important adverse effect of warfarin is hemorrhage of vital organs, such as lung and brain. Diffuse Alveolar Hemorrhage (DAH) is a rare clinical condition which occurs due to variety of medical disorders. Although it's rarely reported, DAH can be a result of coagulopathy prompted by warfarin therapy. In this study we present a case of DAH, caused by warfarin toxicity which referred to the hospital with non-specific respiratory symptoms.. A 41-year-old female patient referred to the hospital complaining of shortness of breath, cough and dizziness. She had been taking warfarin due to mitral valve replacement for the past 10 years. Her recent symptoms began shortly after taking amoxicillin, a few days before admission. Early clinical examination and paraclinical studies reveal DAH as the cause of respiratory symptoms. The patient was then intubated and received fresh frozen plasma, packed cells and oral vitamin K. Laboratory findings apart from increased INR, PT, ESR and CRP were all within normal range. After the initiation of treatment patient's INR decreased and her clinical condition improved. Follow-up CT-Scan and bronchoscopy also confirmed resolving DAH.. The usage of warfarin in anticoagulation should be closely monitored due to its narrow therapeutic window and other factors, including its interaction with other medications such as antibiotics. Warfarin toxicity can lead to DAH, a life-threatening condition which can be presented with non-specific symptoms and deteriorate patient's clinical condition in a short time. Therefore, it is of utmost importance to watch closely for primary symptoms of such rare incident in patients under warfarin therapy and initiate treatment as soon as possible, to prevent mortality.

Topics: Adult; Amoxicillin; Anti-Bacterial Agents; Anticoagulants; Bronchoscopy; Cough; Dizziness; Female; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli; Respiratory Insufficiency; Tomography, Spiral Computed; Warfarin

The Achilles heel of mechanical valves appears to be the need for anticoagulation. Several different types of mechanical valves have come and gone. The success or lack thereof of these valves depended on their various designs. We compared the two most promising mechanical valves of different eras and the need for anticoagulation through a case review. Both the Medtronic-Hall tilting disc valve and the bileaflet On-X valve were compared and contrasted in terms of durability and management of anticoagulation in high-risk patient populations. We present two cases of challenging anticoagulation management: a patient who underwent a mitral valve replacement with a Medtronic-Hall tilting disc valve who was off anticoagulation for close to six years, and a patient who underwent On-X mitral and aortic valve replacements and suffered a subsequent intracranial bleed requiring surgical intervention. We explore the ethical dilemmas associated with these patients and the risk of restarting anticoagulation for each.

Topics: Adult; Anticoagulants; Aortic Valve; Bioethical Issues; Bioprosthesis; Drug Administration Schedule; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intracranial Hemorrhages; Loeys-Dietz Syndrome; Lung Diseases; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Retreatment; Time Factors; Warfarin

Topics: Anticoagulants; Hematoma; Humans; Lung Diseases; Male; Middle Aged; Warfarin

Antithrombotic therapy could trigger diffuse alveolar hemorrhage (DAH), and there are several case reports of DAH that occurred during antithrombotic therapy (DAH-AT). However, little is known about the clinical features and outcomes of DAH-AT. The purpose of this study was to clarify the features and mortality of DAH-AT.. 76 consecutive patients with DAH who were admitted to our hospital between January 2003 and April 2014 were retrospectively reviewed to identify the clinical features and outcomes of DAH-AT. The primary outcome was 90-day mortality.. Of the 76 patients with DAH, 39 patients (51 %) had DAH-AT, and 37 patients (49 %) had DAH that occurred with no antithrombotic therapy (DAH-NAT). Of the patients with DAH-AT, 25 (64 %) were taking aspirin, 14 (36 %) were taking warfarin, 5 (13 %) were taking clopidogrel sulfate, and 4 (10 %) were taking cilostazol. Pre-existing cardiac disease was present in 23 (59 %) DAH-AT cases and 5 (14 %) DAH-NAT cases. Logistic regression analysis was used to assess the effect of antithrombotic therapy on the mortality of DAH patients, and no significant difference in survival was seen with antithrombotic therapy (OR 1.18, 95 % CI 0.38-3.78).. Antithrombotic therapies had no effect on the 90-day mortality of DAH patients.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Cilostazol; Clopidogrel; Connective Tissue Diseases; Female; Fibrinolytic Agents; Heart Failure; Hemorrhage; Humans; Infections; Lung Diseases; Male; Middle Aged; Neoplasms; Pneumonia; Pulmonary Alveoli; Retrospective Studies; Survival Rate; Tetrazoles; Ticlopidine; Vasculitis; Warfarin

Shrinking lung syndrome is characterized by pulmonary compromise secondary to unilateral or bilateral paralysis of the diaphragm.. Shrinking lung syndrome was diagnosed in a patient with antiphospholipid syndrome after a cesarean delivery at 28 4/7 weeks of gestation. Signs and symptoms included unexplained right-side chest pain, dyspnea, tachypnea, and absent breath sounds at the right base of the lungs. After initiation of corticosteroids, her symptoms resolved.. Although seen in association with systemic lupus erythematosus, shrinking lung syndrome has not been described with antiphospholipid syndrome or during pregnancy. Diagnosis and awareness are important because treatment with moderate- to high-dose corticosteroids appears to improve the clinical outcome.

Topics: Adult; Antiphospholipid Syndrome; Aspirin; Cesarean Section; Chest Pain; Dyspnea; Female; Heparin; Humans; Hyperventilation; Lung Diseases; Oxygen; Prednisolone; Pregnancy; Pregnancy Complications; Radiography; Respiratory Paralysis; Respiratory Sounds; Syndrome; Treatment Outcome; Warfarin

This unfortunate patient case highlights the problems with "overdiagnosis" of HIT. Despite "positive" tests for HIT antibodies, the low pretest probability for HIT and the known propensity of patients with APS to yield false-positive HIT antibody results suggests that the patient did not have a true diagnosis of HIT. Moreover, the early administration of warfarin and the choice of argatroban for parenteral anticoagulation when monitoring was hindered by a prolonged baseline aPTT likely play a key factor in the progression of UE DVT to VLG. Ironically, the problems of anticoagulant monitoring posed by the prolonged baseline aPTT likely contributed to the subsequent overanticoagulation and fatal pulmonary hemorrhage. With benefit of hindsight, avoiding the temptation to test for HIT in a low pretest probability situation, and treatment with either heparin using anti-factor Xa monitoring or with non-aPTT-monitored therapy such as LMWH or fondaparinux would likely have resulted in a more favorable clinical course.

Topics: Anticoagulants; Antiphospholipid Syndrome; Arginine; Diagnostic Errors; Drug Monitoring; Fatal Outcome; Female; Gangrene; Hemorrhage; Humans; Lung Diseases; Middle Aged; Pipecolic Acids; Sulfonamides; Thrombocytopenia; Upper Extremity; Vascular Diseases; Warfarin

Topics: Anticoagulants; Hemorrhage; Humans; Lung Diseases; Male; Middle Aged; Pulmonary Alveoli; Radiography, Thoracic; Tomography, X-Ray Computed; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Drug Overdose; Erythrocyte Transfusion; Fatal Outcome; Female; Hemorrhage; Humans; Lung Diseases; Pulmonary Alveoli; Pulmonary Edema; Respiratory Distress Syndrome; Respiratory Insufficiency; Warfarin

Topics: Aged; Anticoagulants; Arteriosclerosis Obliterans; Hematoma; Humans; Lung Diseases; Male; Tomography, X-Ray Computed; Warfarin

We report a case of Wegener's granulomatosis (WG) with pulmonary hemorrhage also satisfying the criteria for antiphospholipid antibody syndrome (APS). This association has, to the best of our knowledge, never been described before. Pulmonary hemorrhage may be an early manifestation of several immune and idiopathic disorders such as ANCA-associated vasculitis. Several case-reports of APS patients with capillaritis have been described. A possible explanation is that microvascular thrombosis with subsequent increase in vascular permeability facilitates perivascular IgG and complement deposition leading to development of capillaritis. Whether the vascular disease is secondary to thrombosis or vasculitis or both is important in choosing the proper management strategy. We suggest that anticardiolipin antibodies (aCL) should be detected in ANCA-associated vascularitis because they may contribute to life-threatening events superimposed on vascular damage.

Topics: Adult; Anti-Inflammatory Agents; Antibodies, Antineutrophil Cytoplasmic; Anticoagulants; Antiphospholipid Syndrome; Cyclophosphamide; Diagnosis, Differential; Granulomatosis with Polyangiitis; Hemorrhage; Humans; Immunosuppressive Agents; Insulin; Lung Diseases; Male; Prednisone; Tomography, X-Ray Computed; Warfarin

We conducted this study to evaluate whether there is an association between preoperative drug therapy and in-hospital mortality in patients undergoing coronary artery graft surgery. We collected data on 1593 consecutive patients undergoing coronary artery surgery. The relative risk of in-hospital mortality was determined by logistic regression with in-hospital mortality as the dependent variable, and independent variables that included known risk factors and preoperative cardioactive or antithrombotic drug treatment, i.e., age; left ventricular function; left main coronary artery disease; urgent priority; gender; previous cardiac surgery; concurrent cardiovascular surgery; chronic lung disease; creatinine concentration; hemoglobin concentration; diabetes; hypertension; cerebrovascular disease; recent myocardial infarction; prior vascular surgery; number of arteries bypassed; and regular daily treatment with beta-blockers, aspirin within 5 days, calcium antagonists, angiotensin converting enzyme (ACE) inhibitors, digoxin, or warfarin. In-hospital mortality was 3.3%. The relative risk of in-hospital mortality (with 95% confidence intervals of the relative risk) associated with the following drug treatments was: nitrates 3.8 (1.5-9.6), beta-blockers 0.4 (0.2-0.8), aspirin within 5 days 1.0 (0.5-1.9), calcium antagonists 1.1 (0.6-2.1), ACE inhibitors 0.8 (0.4-1.5), digoxin 0.7 (0.2-1.8), and warfarin 0.3 (0.1-1.6). We conclude that in-hospital mortality is positively associated with preoperative nitrate therapy and negatively associated with beta-adrenergic blocker therapy. A significant association between in-hospital mortality and the preoperative use of calcium antagonists, ACE inhibitors, aspirin, digoxin, and warfarin was not confirmed.. We examined the association between common drug treatments for ischemic heart disease and short-term survival after cardiac surgery using a statistical method to adjust for patients' preoperative medical condition. Death after surgery was more likely after nitrate therapy and less likely after beta-blocker therapy.

Topics: Adrenergic beta-Antagonists; Age Factors; Aged; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aspirin; Cardiotonic Agents; Cerebrovascular Disorders; Chronic Disease; Coronary Artery Bypass; Coronary Disease; Creatinine; Diabetes Complications; Digoxin; Female; Fibrinolytic Agents; Forecasting; Hemoglobins; Hospital Mortality; Humans; Hypertension; Logistic Models; Lung Diseases; Male; Middle Aged; Myocardial Infarction; Nitrates; Reoperation; Risk Factors; Sex Factors; Survival Rate; Ventricular Function, Left; Warfarin

Topics: Adult; Anemia; Dyspnea; Hemorrhage; Humans; Lung Diseases; Male; Pulmonary Alveoli; Warfarin

A 62-year-old patient on anticoagulant therapy presented with hemothorax, pulmonary hemorrhages and a high retroperitoneal hematoma with obstruction-infarction of the right kidney. Following plasma infusion and pleural drainage, the clinical condition stabilized and kidney function improved.

Topics: Hematoma; Hemothorax; Heparin; Humans; Infarction; Kidney; Lung Diseases; Male; Middle Aged; Retroperitoneal Space; Warfarin

Both fibrin and tissue macrophages are prominent in the histopathology of chronic inflammatory pulmonary disease. We therefore examined the procoagulant activity of freshly lavaged human alveolar macrophages in vitro. Intact macrophages (5 X 10(5) cells) from 13 healthy volunteers promoted clotting of whole plasma in a mean of 65 s. Macrophage procoagulant activity was at least partially independent of exogenous Factor VII as judged by a mean clotting time of 99 s in Factor VII-deficient plasma and by neutralization of procoagulant activity by an antibody to Factor VII. Immunoprecipitation of extracts of macrophages metabolically labeled with [35S]methionine by Factor VII antibody and analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed a labeled protein consistent in size with the known molecular weight of blood Factor VII, 48,000. The addition of 50 micrograms of unlabeled, purified Factor VII blocked recovery of the 48,000-mol wt protein. In addition, supernatants of cultured macrophages from six normal volunteers had Factor X-activating activity that was suppressed an average of 71% after culture in the presence of 50 microM coumadin or entirely by the Factor VII antibody indicating that Factor VII synthesized by the cell was biologically active. Endotoxin in vitro induced increases in cellular tissue factor but had no consistent effect on macrophage Factor VII activity. We also examined the tissue factor and Factor VII activities of freshly lavaged alveolar cells from nine subjects with clinical and/or histologic evidence of sarcoidosis. Four of the nine subjects expressed increased tissue factor and seven of nine had increased Factor VII activity over the normal range (P less than 0.01). We estimate the mean Factor VII associated with the cells of sarcoid patients to be 4.7 ng/10(6) cells (range 0.4-20) as compared to a mean of 0.74 ng/10(6) cells (range 0.2-2) for that of normal subjects. Along with previous data showing synthesis of plasminogen activator, these findings indicate that human alveolar macrophages normally synthesize and express measurable amounts of the initial enzymes of proteolytic reactions regulating both fibrin deposition and fibrin resorption. Abnormalities in Factor VII activity in a small group of patients with sarcoidosis raise the possibility that modulation of fibrin turnover by macrophages may contribute to the pathology of this and perhaps other interstitial lung diseases.

Topics: Blood Coagulation; Cells, Cultured; Endotoxins; Factor VII; Factor X; Humans; Lung Diseases; Macrophages; Pulmonary Alveoli; Sarcoidosis; Warfarin

During a poorly controlled warfarin treatment, a 51-year-old man developed bleeding in various organs. He presented a pulmonary haematoma with the radiologic appearance of a pulmonary nodule. In the literature we found only one report of a pulmonary haematoma with a similar presentation caused by anticoagulant therapy.

Topics: Diagnosis, Differential; Hematoma; Humans; Lung Diseases; Male; Middle Aged; Radiography; Warfarin

Topics: Aged; Anticoagulants; Hematoma; Humans; Lung Diseases; Male; Radiography; Warfarin

Topics: Hemorrhage; Humans; Lung Diseases; Male; Middle Aged; Mitral Valve Stenosis; Postoperative Care; Warfarin

Two mothers with heart valve prosthesis were treated with warfarin during pregnancy. In the first case a caesarean section was done one week after replacement of warfarin with heparin. The baby died of cerebral and pulmonary hemorrhage. The second mother had a male infant by caesarean section. The baby showed warfarin-induced embryopathy with nasal hypoplasia and stippled epiphyses (chondrodysplasia punctata). Nasal hypoplasia with or without stippled epiphyses has now been reported in 11 infants born to mothers treated with warfarin during the first trimester, and a causal association is probable. In view of the risks to both mother and fetus in women with prosthetic cardiac valves it is recommended that therapeutic abortion be advised as the first alternative.

Topics: Abnormalities, Drug-Induced; Adult; Cerebral Hemorrhage; Cesarean Section; Chondrodysplasia Punctata; Female; Fetus; Heart Valve Prosthesis; Hemorrhage; Heparin; Humans; Infant, Newborn; Infant, Newborn, Diseases; Lung Diseases; Maternal-Fetal Exchange; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Topics: Adult; Anticoagulants; Autopsy; Cardiac Catheterization; Digoxin; Female; Hematoma; Hemorrhage; Humans; Lung Diseases; Pulmonary Artery; Quinidine; Rupture; Warfarin

Topics: Animals; Dog Diseases; Dogs; Female; Hemothorax; Lung Diseases; Pleural Effusion; Warfarin