Legionnaires' disease. Association with severe bronchospasm and hypoventilation

A 31-year-old man with legionnaires' disease, who presented with severe pneumonia and hypoxemia, later developed severe bronchospasm and marked hypercapnia, a complication not previously reported in Legionella infection. He responded to therapy with erythromycin and a bronchodilator.

[Therapy of bronchospasmic crisis of childhood with aminophylline]

We tested a new product containing aminophylline with 1,56% alcohol as therapy of bronchospasm in childhood to evaluate therapeutic activity, tolerance and adverse reactions. Authors confirm the usefulness of this product in childhood but dosage must be individualized with monitoring of theophylline blood levels.

Sustained release aminophylline in asthma and its interaction with rimiterol

Twenty chronic asthmatics who completed a double-blind cross-over study comparing sustained release aminophylline tablets with placebo had a significant improvement in airways obstruction. Inhaled rimiterol and the aminophylline tablets were shown to act in an additive manner. There was a significant reduction in asthmatic symptoms on active tablets. A further nine patients had to be withdrawn from the study because of adverse side effects.

Resistance to pancuronium in an asthmatic patient treated with aminophylline and steroids

A 17 year old male with a history of bronchial asthma was admitted to the intensive care unit in severe respiratory distress. During a two week period of intensive respiratory care he received large doses of aminophylline and corticosteroids. In addition, pancuronium was given to facilitate ventilation and to reduce airway pressure. Large doses of pancuronium, as much as 5 mg/hr, were required to stop spontaneous respiratory efforts and restlessness. The total pancuronium dose given during the two week period was 800 mg. One hour after pancuronium was discontinued the patient could open his eyes and move his lips. Peripheral nerve stimulation indicated partial paralysis which improved promptly following a test dose of edrophonium. The authors speculate the aminophylline, which is a known inhibitor of the enzyme phosphodiesterase, raised the level of c-AMP and, in turn, the level of acetylcholine at the neuromuscular junction and thus antagonized the blocking effect of pancuronium. In addition, the large doses of corticosteroids that the patient had received may have enhanced the release of acetylcholine and further facilitated neuromuscular transmission.

The diaphragm in health and disease

The diaphragm consists of two separate muscles, the costal and crural parts, with different segmental innervation and different action on the rib cage. Diaphragmatic endurance is determined by the balance between energy supply and demand. Both an increase in demand and a decrease in supply of energy lead to diaphragmatic fatigue. Under conditions of reduced O2 transport to the body, the inspiratory muscles may command a disproportionate amount of the total body O2 consumption, particularly if the work of breathing is increased. Their energy demands may thus contribute significantly to the pathogenesis of cardiogenic shock and lactic acidosis. Inspiratory muscle fatigue can be diagnosed by observing and palpating: (1) abdominal paradox, a fall in abdominal pressure and an inward displacement of the abdomen during inspiration, and (2) respiratory alternans, a variation in abdominal pressure changes from breath to breath, reflected in variations in the inspiratory movements of rib cage and abdomen. Treatment consists in decreasing energy demands and increasing supplies. Artificial ventilation should be considered to accomplish the former. Methyl xanthines improve diaphragmatic contractility and specific diaphragmatic training programs improve diaphragmatic endurance.

Theophylline serum concentration and therapeutic effect in severe acute bronchial obstruction: the optimal use of intravenously administered aminophylline

In 20 patients with acute exacerbation of bronchial obstruction, the therapeutic effect of high (20 mg/L) and low (10 mg/L) serum concentrations of theophylline was compared in a double-blind randomized study. The theophylline dose, administered as a continuous aminophylline infusion, was individually adjusted by means of repeated measurements of serum concentrations. At 28 h after starting therapy the high concentration group showed a significantly greater improvement in pulmonary function as assessed by FEV1 (0.57 +/- 0.52 L (mean +/- SD) versus 0.1 +/- 0.18 L, p less than 0.01) and FVC (1.0 +/- 0.65 L versus 0.01 +/- 0.66 L, p less than 0.02). As a measure of the overall clinical improvement, the time during which intravenous therapy was required was also shorter in the high-dose group (61.7 +/- 25.8 h (mean +/- SD) versus 116 +/- 49.7 h, p less than 0.02). The occurrence of side effects in the two groups was not significantly different. In patients with severe acute bronchial obstruction, serum theophylline concentrations around 20 mg/L seemed to offer a definite therapeutic advantage, thus, routine serum concentration measurements and the use of accurate infusion devices for optimal dose adjustment may be justified.

Pharmacokinetics of theophylline in infants with bronchiolitis

Theophylline pharmacokinetics were studied in 12 infants (age 3 weeks-6.5 months) with bronchiolitis. 9 of the 12 patients received a single dose of aminophylline (5.0-8.5 mg/kg) whereas the remainder were at steady-state receiving multiple doses (2.5-5.0 mg/kg) of aminophylline. The dose was administered IV over 0.5-1.0 h. An HPLC method was used to measure theophylline concentrations in serum and urine. Peak serum concentrations of theophylline measured by HPLC ranged from 8.48-21.6 micrograms/ml. Total, renal and nonrenal clearance of theophylline ranged from 4.66 to 19.25, 1.07 to 5.76 and 3.59 to 16.83 ml/min/m2, respectively. Mean apparent volume of distribution and elimination half-life were 8.75 l/m2 and 11.38 h, respectively. Although no significant correlation was observed between age and theophylline kinetic parameters, clearance appeared to increase and half-life decrease with age. Our patients had a substantially lower clearance and longer half-life as compared to published data in children greater than 1 year of age. A five-fold variation in theophylline clearance demonstrates the need for monitoring theophylline serum concentration to minimize the risk of potential toxicity.

Clenbuterol ("Spiropent'): a long-acting bronchodilator

Clenbuterol was compared to an aminophylline preparation in a double-blind crossover trial involving 47 patients with asthma and reversible airways obstruction. Following a 2-week control period, each drug was given for a 4-week period. The patients made daily records of the severity of symptoms and recorded PEFR morning and night. Both drugs produced a highly significant reduction in severity and duration of wheeze by day during the first 4 weeks, but only clenbuterol produced further significant reduction in these symptoms during the second 4 weeks. Only clenbuterol produced a significant reduction in the severity of wheeze at night. When clenbuterol was given first there was a significant increase in the mean PEFR both night and morning but no other significant changes with either drug at other periods. Combining the results from the two treatment groups showed a significant difference between them in favour of clenbuterol in respect of duration of daytime wheeze only (p less than 0.05).

[Experience in using glutamic acid electrophoresis in the early treatment of craniocerebral injuries]

Endonasal electrophoresis with alpha-glutamic acid was used in 76 patients with severe craniocerebral injury. The result was good in 24 (38%) and satisfactory in 40 (55%) patients. Thus, a positive result of treatment was obtained in 88% of cases, which was confirmed by electrophysiological and neuropsychological studies. The method produced the greatest effect on the patients' psychic status: 74% of all disorders of higher psychic functions, mainly memory, were restored on the average by the end of treatment. Good tolerance of electrophoresis and its efficacy in the early period after severe injury, i. e. in the first month, were established. Contraindications for treatment were defined more precisely. Since the method is simple and does not call for special conditions, it may be widely used in any medical establishment equipped with galvanization apparatuses.

Myocardial imaging with dipyridamole: comparison of the sensitivity and specificity of 201Tl versus MUGA

Myocardial imaging was performed at rest and after dipyridamole infusion using 201Tl and 99Tcm - gated blood pool studies (MUGA). Of 38 patients studied, 21 had coronary artery disease (CAD) and 17 were normal. With 201Tl imaging, 19 of 21 patients with CAD (sensitivity 88%) showed perfusion defects during dipyridamole. Of 17 normals 6 (specificity 65%) showed clear perfusion defects during dipyridamole. With MUGA, 2 of 15 patients with CAD (sensitivity 13%) developed abnormal wall motion during dipyridamole; both patients developed ST depression greater than 1 mm. Of 10 normals none developed abnormal wall motion. Twenty six of 38 patients developed angina during dipyridamole, which was reversed by aminophylline in 24 of 26. We suggest that dipyridamole infusion is effective for 201Tl-perfusion imaging, and easily performed, but is not suitable for MUGA studies where ischaemia is the required endpoint.

A controlled study of slow-release theophylline and aminophylline in patients with chronic bronchitis

Twenty patients with chronic bronchitis who were also receiving beta-agonist inhalers entered a single-blind cross-over study comparing slow-release aminophylline (Phyllocontin) 325 mg twice daily and slow-release theophylline (Rona-slophyllin) 250 mg twice daily with placebo. 16 subjects who completed the study showed no objective or subjective benefit with either active preparation. Eight of the 16 patients achieved plasma theophylline levels of greater than 10 micrograms/ml on each of the drugs but no benefit was found when this group was analysed separately.

[Relation of dose, serum concentration and side effects in intravenous aminophylline therapy]

Routine intravenous aminophylline therapy was monitored by drug level measurements in 45 hospitalized patients with chronic obstructive bronchitis. Only 44% had theophylline serum concentrations (Cp) in the optimum range (10-20 mg/l), while in 36% of patients potentially toxic Cp values were observed. The incidence of side effects was related to theophylline serum concentration: 78% in cases with Cp greater than 30 mg/l against 24% in cases with Cp less than 20 mg/l. Theophylline toxicity occurred most frequently in elderly patients with cardiac failure, who had markedly reduced theophylline clearances. To avoid excessive drug accumulation the usual aminophylline dose should be reduced by 50% when clinical signs of cardiac failure are present. In addition, measurement of theophylline serum concentration is often necessary for optimum dosage adjustment.