Thai Journal of Tuberculosis Chest Diseases and Critical Care

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    รายงานผู้ป่วยโรคเบาหวานที่มีการติดเชื้อรามิวคอร์ที่ปอด ในสถาบันโรคทรวงอก
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2009-12-22) Sudarat Siripataravanit
    Abstract: Siripataravanit S. Diabetic patients with localized pulmonary mucormycosis in Chest Disease Institute.Thai J Tuberc Chest Dis Crit Care 2009; 30: 53-62.Chest Disease Institute, Department of Medical Services, Ministry of Public HealthIntroduction: Pulmonary mucormycosis is an uncommon, but important, opportunistic fungal pneumonia which isoften diagnosed post mortem. Delay in diagnosis may lead to high mortality.Objective: This review emphasizes clinical and pathologic characteristics of pulmonary mucormycosis amongdiabetes mellitus (DM) patients.Material and Methods: Medical records (age, sex, underlying diseases, symptoms, signs, and outcomes),pathology reports, chest radiographs, CT chest of 3 cases of pathologically proven pulmonary mucormycosis inChest Disease Institute between January 1, 1997 and July 31, 2008 were retrospectively reviewed.Results: There were 3 cases with pathologically proven pulmonary mucormycosis (2 male, 1 female, mean age61 years, range 49-74 years). The mean duration of the disease before treatment was 4 months (range 1-9months). The common clinical presentations were productive cough (n=3) and hemoptysis (n=2). Physicalexaminations were normal (n=2) and rhonchi (n=1). Abnormalities seen on chest radiographs and CT chestincluded mass like lesion in upper lobe (n=2; 1 left, 1 right) and consolidation at left upper lobe (n=1).Endobronchial appearance by fiberoptic bronchoscopy were mass-like lesion (n=2) and mucopurulent discharge(n=1). Culture from clinical specimens were negative in all patients. All patients had successful treatment withamphotericin B and surgery.Conclusion: Pulmonary mucormycosis infections are still uncommon, but the incidence in the immunocompromisedhost and diabetic patients has increased significantly. Early consideration of this diagnosis, along with aggressivediagnostic evaluation, are critical to effective therapy and patient survival. While treatment with amphotericin B isthe mainstay of therapy for pulmonary mucormycosis, diabetics with endobronchial disease may benefit from early,aggressive surgical resection of the involved lung tissue.
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    The Surveillance of Drug Resistant Tuberculosis in the Lower North of Thailand between 2005-2007
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) R. Khummin
    This retrospective study is done to determine situation and trend of multi-drug resistant tuberculosis (MDR-TB). The whole study retrieved 2,901 clinical specimens (sputum pus blood and urine) from hospitals in control of The Office of Diseases Prevention and Control 9th Phitsanulok, 2006-2008. There were 392 drug susceptibility tests (13.48%) form The national tuberculosis reference laboratory. The result revealed drug resistance for isoniazid (H) 43 (11%), rifampicin (R) 14 (3.58%), streptomycin (S) 28 (7.16%) isoniazid (H) 6 (1.53%). H with R (1.79%), H with S (1.53%), H with E (0.26%), H with S and E (0.77%), S with R and E (0.26%), H with R and E (1.79%), H with R and S (1.54%), resistance for all drugs 4.6%. There were 20 MDR-TB cases (5.12%) and nontuberculous mycobacteria, (NTM) 18 cases (4.6%). MDR-TB is the best index for National TB programme treatment quality and TB planning. This study shows high prevalence and upward trend for MDR-TB. However, this study retrieved some specimens from this area. It is possible that there were more cases of MDR-TB in this area.
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    Asthma Remission
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) K. Maneechotesuwan
    Treatment with inhaled corticosteroids could induce asthma remission at clinical levels but could only reduce Th2 cytokine-mediated airway inflammation therefore ongoing airway inflammation still exists and asthmatic symptoms may be relapse in patients with severe asthma. Mechanisms underlying ongoing airway inflammation are associated with environmental epigenitics, Th2 polarization, suppression of indoleamine 2, 3 dioxygenase (IDO) after allergen exposure, and ICS-resistant neutrophilic airway inflammation induced by Th17 cells. Environment epigenetics is induced by appropriate environment stimuli including cigarette smoking which result in favour of Th2 cytokine production but reduce Th1 cytokines. Th2 polarization is rather irreversible process, which causes the increase of Th2 cell numbers and Th2 cytokine release. Aeroallergen in particular house dust mite could suppress immunosuppressive activity of IDO in dendritic cells, thus enhancing airway inflammation. Th17 cells are a major source of interleukin-17 which is chemoattractant for neutrophil therefore induces neutrophilic airway inflammation. Recent study has demonstrated that there is an increase in Th17 cells in patients with steroid-resistant severe asthma in association with neutrophilic airway inflammation, possibly contributing to the mechanism responsible for steroid-resistance in asthma.
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    การพัฒนารูปแบบการพยาบาลผู้ป่วยโรคหลอดลมอุดกั้นเรื้อรัง ในโรงพยาบาลศรีสะเกษ
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2009-12-22) Angkana Boonlop
    Abstract: Boonlop A. The development of nursing care model for chronic obstructive pulmonary disease (COPD)patients in Si Sa Ket Hospital. Thai J Tuberc Chest Dis Crit Care 2009; 30: 46-52.Si Sa Ket Hospital, Ministry of Public HealthChronic obstructive Pulmonary Disease (COPD) is progressive and irreversible disease. COPD patientshave variety of problems such as physical, emotional, social, spiritual and economy problems. These causepatients unable to coping with strengthening ability. Many COPD patients were re-admitted to hospital and poorquality of life. Some COPD patients still lack of knowledge and skill in muscle training.The records of COPD with acute exacerbation admitted to Si Sa Ket Hospital between 2004-2007 werestudied. There were 365, 410, 390 and 448 patients, respectively. COPD patients who were re-admitted within 28days after discharge were 56, 34, 47 and 15 patients, respectively. We developed Clinical Practice Guideline(CPG) for Patient with Chronic Obstructive Pulmonary Disease and evaluate its utility.Objectives: To study the impact of CPG for COPD patients in various aspects such as mortality rate, re-admissionnumber, complication and cost of treatment.Methodology: The descriptive study was done in 26 COPD patients admitted to Si Sa Ket Hospital duringNovember 2007 - June 2008. All the clinical data were analyzed by percentage, mean, range and frequency.Results: The percentage of medical personnels who use CPG for COPD patient were; Doctor 100%, Nurse 100%,Pharmacists 100%, Rehabilitants 88% and Nutritionist 80.77%. COPD patients 96.15% were male and 3.85% werefemale. Age is between 47-78 years. Mortality rate was decreased from 1.85% (2007) to 0% (2008). Length of staywas decreased from 4.59 to 2.88 days. Re-admission within 28 days after discharge was decreased from 5.56 to3.85 days. 4% of acutely exacerbated COPD patients were intubated and the cost of treatment was decreasedfrom 13,220 to 5,718 bahts.
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    Respiratory mechanics of infants with bronchopulmonary dysplasia who required long term oxygen therapy
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) T. Chaisupmongkollarp; A. Preutthipan; P. Nannarumitre; U. Udomsubpayakul
    Respiratory mechanics (RM) were prospectively and longitudinally studied in a cohort of 23 infants with bronchopulmonary dysplasia (BPD).\  The aim of this study was to compare pulmonary function in BPD infants who required supplemental oxygen for more than 2 months (the study group, n=15) and in age-matched BPD infants who required supplemental oxygen at 2 months or less (the control group, n=8). Serial pulmonary functions were measured, using a computerized infant pulmonary function device (model 2600; SensorMedics; Yorba Linda, CA, USA), at 6, 12, 18, and 24 months of corrected age. Both groups did not differ for sex, birth weight, gestational age, duration of mechanical ventilation, history of patent ductus arteriosus or respiratory distress syndrome. At 6 months of age, compliance of the respiratory system (Crs) in the study group was significantly lower than the control group (6.8\±2.9 vs. 11.7\±3.6 ml/cm H₂O, p \< 0.05) and at 6, 12, and 18 months of age. Tidal volume in the study group was significantly lower than the control group (43.8\±11.9 vs. 62.4\±14.9 ml; 62.1\±11.8 vs. 79.7\±15.9 ml; 79.9\±14.2 vs. 96.5\±19.1 ml; p \< 0.05).\  Other pulmonary function including functional residual capacity and total respiratory system resistance (Rrs) did not differ between the two groups. We conclude that the pulmonary function status of BPD infants who required supplemental oxygen for more than 2 months need longer time period for recovering from lung injury than the control group.
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    State-of-the-Art : เหลียวหลัง แลหน้า การควบคุมการบริโภคยาสูบของประเทศไทย
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-07) สงคราม ทรัพย์เจริญ
    Abstract not available
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    Comprehensive Management Program in COPD Patients
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) K. Pipatvech
    Background: Chronic obstructive pulmonary disease (COPD) was non-communicable disease which gradually increasing incidence. The mortality might be twice in the next decade and also the trend of ER visit and admission rate. These resulted in higher cost of treatment. Until now, there was no best holistic clinical practice guideline for the general practitioners. The establishment of holistic clinical practice guideline for COPD management might be the best for both patients and physicians. Objective: To assess outcome of treatment before and after apply the comprehensive management program in COPD patients. Setting: Uttaradit Hospital. Study design: Prospective cohort study. Method: Prospective study was conducted in COPD patients during November 2007 to October 2008 compared to pre-protocol period. Results: There were 137 COPD patients included in the study. Six patients were excluded. Their mean age was 68 years old. Most of them (79%) were male. Smoking was the major risk factor. Less than half of them had underlying disease with hypertension the most common. The mean BODE index was 3.14. Their pulmonary function test results were classified as moderate to severe disease. Male dyspneic scale (Modified Medical Research Council scale, MMRC) was higher than female but not correlated with the severity of disease. Rescued bronchodilator therapy was a main treatment in these patients. After the program implementation, there were significantly declined in the dyspneic scale, acute exacerbation rate, re-admission and cost of treatment (p \< 0.0001). The thirty meters increment of six-minute walk distance and minimal clinical important difference (MCID) were improved, compared to pre-implementation period (54.69, 43.75 respectively). Conclusion: The implementation of comprehensive management program in COPD patients resulted in significant improvement of the dyspneic scale, acute exacerbation rate, re-admission and cost-saving in hospital.
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    บรรณาธิการแถลง
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-07) วันชัย เดชสมฤทธิ์ฤทัย
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    Solitary Fibrous Tumor of the Pleura: A Case Report
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2009-12-22) Supawadee Makanut
    Abstract: Makanut S, Tscheikuna J, Suthinont P, Thongcharoen P. Solitary fibrous tumor of the pleura: a casereport. Thai J Tuberc Chest Dis Crit Care 2009; 30: 63-71.Faculty of Medicine, Siriraj Hospital, Mahidol UniversitySolitary fibrous tumors of the pleura are rare tumors arising from submesothelial mesenchymal tissue ofthe pleura. Most of the tumors have benign clinical behavior with satisfactory outcome if resected completely.Some of the tumors are malignant and eventually lead to death through local recurrence or metastatic disease.Patients with the tumors had various clinical features, ranging from no symptoms, local symptoms such asdyspnea, cough and chest pain, and systemic symptoms such as clubbing and hypoglycemia. We report a caseof a 30 year-old female patient with solitary fibrous tumors of the pleura. At presentation she had nonproductivecough, dyspnea and weight loss for 4 months. Chest radiography revealed a well-circumscribed large homogenous,pleural based extrapulmonary mass at left hemithorax. Ultrasound-guided biopsy of the pleural massshowed benign fibrous lesion markedly positive with CD34 and negative for smooth muscle actin and S-100. Shewas treated with left posterolateral thoracotomy with en bloc tumor resection. The tissue pathology showed solitaryfibrous tumors of the pleura with mitotic figure 0-1/50 HPF, no area of tumor necrosis and free surgical margin.The surgical treatment resulted in good outcome without post-operative complication.
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    Implication of the sepsis treatment protocol in Uttaradit Hospital for improving mortality rate
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-08) K. Pipatvech
    Background: The high mortality rate of septic patients in Uttaradit Hospital was due to the delay in diagnosis and improper management in the first six hours. The integration of sepsis treatment protocol into clinical practice might be useful tool for rapid diagnosis and treatment. Early attack to source of infection and effective supportive treatment may lead to normal organ system function and also reduce the complications, mortality rate and cost of treatment. Objective: To assess mortality rate before and after implementation of sepsis treatment protocol in Uttaradit Hospital. Method: This prospective study were conducted in post-protocol septic patients during August 2007 to January 2008 compared with retrospective medical reviews in pre-protocol septic patients during February to July 2007. Result: There were 448 septic patients included in the study. Four patients were excluded because of failure to fulfil the diagnostic criteria. The mean age of both groups were 62 years old. Mean APACHE II score were 22.57 VS 23.1. After septic protocol implementation, the mortality rate was significantly reduced from 67% to 52% (p \< 0.001). The inadequate fluid resuscitation, delayed starting time of initial antibiotic treatment and organ failure were associated with increasing mortality rate (p \< 0.001) in both groups. Rate of ICU transferring was increased from 18% to 43% (p \< 0.001) as well as rate of initial antibiotic receiving in three hours from 49% to 63% (p=0.02). Furthermore, the length of hospital stay tended to be shorten in contrast with prolonged ICU stay (p=0.99, 0.13 respectively). The pre-protocol cost of treatment was not increased compared to the post-protocol (p=0.15). Conclusion: The implementation of sepsis treatment protocol was benefit for mortality rate improvement but not for hospital cost-saving.
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    Sleep Problems in Critically Ill Patients
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) N. Jaimchariyatam
    Critically ill patients are known to suffer from severely fragmented sleep even if the total sleep time is often less decreased. In addition to severity of diseases itself, the critical care environment is also a harsh one for sleep. Given that the patients usually spend as much time sleeping during the day as at night, the circadian rhythm is also affected accordingly. The severely fragmented sleep is attributed to frequent arousals and awakenings during sleep. The sleep architecture with a predominance of stage I sleep and a paucity of slow wave and REM sleep is often seen in critically ill patients. Several factors are believed to contribute to sleep disruption found in critically ill patients. Basically, noise, patients care, medication, medical illness, and psychological stress from disease have been considered to be important factors. The clinical importance of this type of sleep disruption in critically ill patients, however, is not known. Recently, there has been a lot of evidence demonstrating the role of ventilator itself in disturbing sleep quality and quantity. Additionally, the studies revealed that sleep fragmentation may also influence multiple aspects of a critically ill patientûs course, response to treatment, and ultimate outcome. Accordingly, understanding and prompt treatment of sleep deprivation in critically ill patients may have further improved the treatment effects of conventional treatments.
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    คำที่มักใช้ผิด
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) วันชัย เดชสมฤทธิ์ฤทัย
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    The result of DOTS program to control tuberculosis in Sawanpracharak Hospital during 2003-2005
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) Teerasak Laksananun
    The objective was to study the result of DOTS program to control tuberculosis in Sawanpracharak Hospital. It was the  retrospective descriptive study of pulmonary tuberculosis (New M+) register in provincial Sawanpracharak Hospital during 2003-2005. The data were collected from 401 new TB cases register and were presented as basic statistics, percentage and mean. It was found that smear-positive pulmonary tuberculosis affected male more than female (ratio 1.8 : 1). The most common age-group was more than 65 years old (25.68%). The second most common age-group was between 35-44 years old (20.95%). The sputum conversion rate was growth from 54.92 in 2003 to 80.72% in 2004 and 82.43% in 2005. Between 2003 to 2005, the cure rate was increased from 56.03 to 77.63 and 78.72%, success rate was increased from 58.62 to 82.89 and 80.82% and default rate was decreased from 8.62 to 2.63 and 4.26%, respectively. The treatment outcome result was improved due to development in TB clinic management, such as organization of tuberculosis treatment service, participation of health officers, doctors, nurses and TB registration system. TB patients were given standard treatment in daily pack by pharmacist and were followed up and evaluated every month. The treatment outcome result in Muang district, Nakhonsawan, was better than in rural countries because of health volunteers from Global Fund. However, tuberculosis control result was lower than WHO standard. Suggestion for DOTS strategy was active case finding in contacted and suspected cases in the community. If the system of case finding is widely developed, tuberculosis control will be improved.
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    Tuberculosis of Cervix
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) Niran Sukprasert
    A rare case of cervical tuberculosis, which was referred to the author as cancer cervix is presented. This case emphasizes that though uncommon, tuberculosis is an important alternative in the differential diagnosis of a malignant appearing lesion of the cervix. This is especially true in our country with high prevalence of tuberculosis and, therefore, a high index of suspicion is warranted. Tuberculosis is not uncommon in the developing country. I describe a patient who attended at gynecological clinic and was found to have cervical tuberculosis without association with HIV infection.
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    Acute Respiratory Distress Syndrome (ARDS) in Ramathibodi Hospital: Risks and Prognostic Factors
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-08) Kittima Bangpattanasiri; Sumalee Kiatboonsri; Sasivimol Rattanasiri
    Objectives: To study the outcome of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in medical ICU, Ramathibodi Hospital and identify factors that contribute independently to mortality. Study design: Retrospective study. Methods: All patients admitted in medical ICU between January 1998 and December 2002, that met the criteria of the American-European Consensus Conference for ALI and ARDS were reviewed. The data collection included patient baseline characteristics, risk factors for ARDS, initial PaO₂/FiO₂, PaO₂/PAO₂, static lung compliance, best PEEP level, APACHE II score, associated early and late nonpulmonary organ dysfunction, mode of ventilator, ventilator days, outcomes and complications. The probability of death and median survival time were assessed by Kaplan-Meier method. Prognostic factors associated with mortality were determined by Cox Proportional Hazard method. Results: A total of 48 patients met the criteria of ALI and ARDS. The mean age of these patients was 46.8 \±18 yrs. Direct lung injuries were the most common causes of ARDS in this series (35/48), of which pneumonia attributed to the majority of cases (80%). The mean APACHE II score of the group was 20.9\±7.4, with 70.8% hospital mortality. Main cause of death was multiple organ dysfunction, while refractory hypoxemia was less common. Factors independently associated with mortality were initial APACHE II score of more than 20 (hazard ratio, 2.09; 95%CI 1.02 to 4.32) and the presence of circulatory dysfunction 24 h after the onset of ARDS (hazard ratio, 5.78; 95%CI 2.11 to 15.86). Conclusion: Mortality rate of ARDS in medical patients had been unchanged. The extreme high mortality (70.8%) in this group could be due to the high proportion of patients with pneumonia and sepsis. Only initial APACHE II score of more than 20 and the presence of circulatory dysfunction were found to be the independent predictors of mortality. These further confirmed and emphasized the concept of \“lung as a part of systemic inflammatory process\” in ARDS.
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    Update in Pulmonary Hypertension
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) ณัฐพงศ์ เจียมจริยธรรม
    Abstract not available
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    Melioidosis in Budhachinaraj Hospital in 2004-2007
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-09) P. Treebupachatsakul
    Background: Melioidosis has been regarded as a geographic-related infectious disease, specifically the northeastern part of Thailand. There are limited reports in other areas, particularly in lower northern part of the country. Objectives: This study aimed to explore clinical characteristics, clinical outcomes and determine risk factors for death in patients with melioidosis in Buddhachinaraj Hospital. Method: Clinical analysis was performed in all medical records of patients who 1) melioidosis was diagnosed or 2) positive culture or 3) melioidosis titer \> 1 : 160, admitted in Buddhachinaraj Hospital during January 2004 to December 2007. Results: One hundred and thirteen patients were enrolled, 64 cases (56.6%) were culture-proven (definite melioidosis) and 49 cases (43.4%) were propable melioidosis (no culture-proved, diagnosed by clinical features and positive melioidosis titer). All of patients resided in Phitsanulok and nearby provinces. There were more common during rainy season and also related with the amount of the rain. Exposure clues were found in 46.9% of patients. Underlying co-morbid conditions were identified in 54.9% of patients. Diabetes mellitus was the most common (47.8%). The involved sites were lungs (53.1%), liver (55.8%), spleen (21.2%), skin and soft tissue (10.6%), genitourinary tract (9.7%), bone and joint (6.2%), lymph nodes (4.4%), CNS (2.7%), and pericardium (2.7%). Blood culture was positive in 33.6% of patients. Comparing survivors and non-survivors, prompt appropriated antibiotic were used in 79.7%, 20.3%, respectively (p \< 0.001). Patients with septicemic form (OR=34.39), positive blood culture (OR=4.22), acute onset (OR=3.05), pre-existing liver diseases (OR=3.96), lung involvement (OR=2.61), and inappropriate antibiotic within first 48 hours (OR=7.22) were significantly related to higher mortality. Conclusions: This study confirmed that melioidosis is prevalent in lower north of Thailand and yet, greatly underestimated. Better awareness, both among clinicians and microbiologists, couple with improving diagnosis methods to allow early diagnosis and hence early treatment, will significantly reduce the morbidity and mortality associated with melioidosis. Locally adapted guidelines are needed to be developed for the treatment of sepsis, especially from community-acquired pneumonia in the patients at risk.
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    Result of the trans-thoracic fine needle aspiration of the mass-like lung lesion under computed tomography guidance
    (Thai Journal of Tuberculosis Chest Diseases and Critical Care, 2010-04-08) P. Subhannachart; C. Vijitsaghuan; S. Tungsagunwattana; S. Nikomprasart
    The purposes of the study: To assess the sensitivity of the trans-thoracic fine needle aspiration of the mass-like lung lesion and the factors influenced satisfied specimen. To evaluate the complication rate of this procedure and the factor that increased the risk of complication. Materials and Methods: This study was done retrospectively in the 320 patients had mass-like lung lesion who trans-thoracic fine needle aspiration were done under computed tomography guidance. Results: The satisfied specimen from this procedure was 92.2%. The sensitivity of this procedure was 91.5% for malignant lesion, 50% for tuberculous infection, and 34.4% for other infections or inflammatory lesions. The satisfactory of the specimen tended to decrease slightly in the deeper lesion. Pneumothorax was the most common complication, found in 14.4% and only 1.6% required intercostal chest drainage. The factors influenced increasing pneumothorax rate were passing of needle through emphysematous lung, passing of the needle through the fissure, and needle passing the lung more than 1 centimeter. Conclusion: The trans-thoracic fine needle aspiration of the mass-like lung lesion had high sensitivity especially in malignant lesions. The complications were low and mild. The most common complication was pneumothorax. To decrease risk of pneumothorax, avoidance of passing the needle through emphysematous lung and fissure should be considered.