Unilateral absence of ventilation and perfusion associated with a bronchial mucous plug

We have described a patient in whom loss of ventilation and perfusion of an entire lung resulted from mucous impaction of a major bronchus. Mucous plugging was associated with the combination of asthma and decreased cough effectiveness due to paraplegia. Removal of the obstruction by bronchial aspiration followed by vigorous pulmonary physical therapy resulted in return of both ventilation and perfusion to the lung and relief of dyspnea and hypoxemia.

Antibody coating and quantitative cultures of bacteria in sputum and bronchial brush specimens from patients with stable chronic bronchitis

Antibody coating of bacterial isolates has been proposed as a method of identifying bacteria responsible for chronic lower respiratory infections. This study was designed to determine the specificity of antibody coating by examining bronchial secretions obtained from a group of patients with chronic bronchitis who had no clinical evidence of acute infection. Routine and quantitative bacterial cultures were performed at the same time. The bronchial brush specimens contained potentially pathogenic bacteria in all 18 patients examined, and 17 of these 18 specimens had antibody coating of bacteria. Quantitative cultures yielded greater than 10(4) colony forming units in only one patient and he subsequently developed a lower respiratory tract infection. We conclude that in patients with chronic bronchitis, the determination of antibody coating of bacterial isolates does not significantly increase the specificity of routine culture. Quantitative cultures of specimens obtained via the protected brush catheter are useful in identifying potential pathogens.

Effect of aminophylline on exercise performance in patients with irreversible airway obstruction

Thirteen clinically stable male patients aged 63 +/- 3 years with irreversible airway disease were given aminophylline and placebo in a randomized crossover fashion on two consecutive days while receiving beta-agonists. During incremental exercise the maximal heart rate (139.0 +/- 22.1 vs 128.0 +/- 16.4 beats per minute) and minute ventilation (41.9 +/- 6.9 vs 38.1 +/- 8.2 L/min) were significantly higher and the arterial carbon dioxide pressure (34.6 +/- 5.0 vs 38.6 +/- 7.7 mm Hg) was significantly lower during aminophylline administration than during placebo administration. However, spirometric findings, maximal inspiratory pressures, maximal oxygen consumption, work rate, and arterial oxygen pressure were similar on both regimens. We concluded that the major effect of aminophylline is to increase ventilatory drive in patients with irreversible airway obstruction. Unless an objective change in spirometric data or exercise capacity can be documented, we believe that aminophylline therapy is not warranted in these patients.

Optimal dose of fenoterol by metered-dose inhaler in asthmatic adults

Three doses of fenoterol were administered by metered-dose inhaler to 20 adult subjects with asthma in order to determine the optimal dose for routine administration. Inhaled doses of 100 micrograms, 200 micrograms, and 400 micrograms of fenoterol with isoproterenol and placebo controls were administered in a randomized double-blind crossover regimen. We found that 200 micrograms of fenoterol by metered-dose inhaler produced a longer duration of action, greater peak response, and greater overall time-weighted responses in the forced expiratory volume in one second, in the mean forced expiratory flow during the middle half of the forced vital capacity, and in airway resistance than did the other drug regimens. The 400 micrograms dose of fenoterol produced no increase in response over that seen after the 200 micrograms dose. Side effects were minimal and no greater than with isoproterenol.

Antigen detection in the diagnosis of fungal respiratory infections

The diagnosis of fungal infections of the respiratory tract is often difficult and may require invasive diagnostic procedures. The detection of soluble fungal antigens in bodily fluids such as serum, pleural fluid, and bronchoalveolar lavage fluid may substantially improve the ability to diagnose fungal respiratory diseases. For instance, uncommon presentations of diseases with the pathogenic fungi, such as chronic cavitary histoplasmosis, coccidioidal empyema, and cryptococcal pneumonia are often difficult to diagnose with present techniques, and the detection of fungal antigens may prove to be more sensitive. There is an especially urgent need for sensitive, reliable, commercially available tests for the diagnosis of opportunistic fungal pneumonias that occur in immunocompromised hosts. Preliminary data holds promise for the noninvasive diagnosis of deep-seated candidiasis (including pneumonia) and pulmonary aspergillosis by the detection of fungal antigens in serum and bronchoalveolar lavage fluid. We review current techniques used for the detection of fungal antigens, including their sensitivity and specificity, and their use in diagnosing human infections.

Comparison of the effects of labetalol and hydrochlorothiazide on the ventilatory function of hypertensive patients with asthma and propranolol sensitivity

Previous studies have shown that labetalol, a new alpha- and beta-adrenergic antagonist, is relatively safe for the treatment of hypertension in patients with chronic obstructive pulmonary disease (COPD). This multicenter study was designed to evaluate its effects in hypertensive patients with asthma and propranolol sensitivity. Hypertension was successfully controlled in 18 of 21 patients who received labetalol in increasing doses, up to 1,200 mg/day. The decrease in mean FEV1 (1.5 percent) two hours after the highest dose of labetalol was not statistically significant, although there was a gradual decline in mean baseline FEV1 during the four-week treatment period. Antihypertensive agents other than adrenergic antagonists should be considered for the management of hypertension in patients with asthma, especially those with marked reversibility of airflow. If treatment with beta-adrenergic antagonists is indicated, labetalol is recommended over other currently available agents.

Effect of steroid therapy on exercise performance in patients with irreversible chronic obstructive pulmonary disease

Many patients with irreversible chronic obstructive pulmonary disease (COPD) claim symptomatic improvement with steroid therapy, despite a lack of objective improvement in their spirometric data. To determine if steroids actually increase the exercise capacity of these individuals, 13 clinically stable patients (mean age, 63 +/- 4 years; 12 male patients) were given methylprednisolone (32 mg once daily) or placebo in a randomized double-blind crossover fashion. Spirometric data and minute ventilation, oxygen consumption (VO2), carbon dioxide production, and heart rate during incremental exercise were measured at each visit. Methylprednisolone did not produce a significant change in any of the measured parameters. Three patients had an increase in maximal VO2 of greater than 2 ml/kg/min during therapy with methylprednisolone, while two experienced a decline in maximal VO2 of similar magnitude. The change in exercise capacity was unrelated to the change in the forced expiratory volume in one second in individual patients (r = 0.08). We conclude that in the absence of any improvement in the usual tests of airway mechanics, steroid therapy does not improve exercise performance in patients with COPD.

Inability of awake patients to correctly locate a cough stimulus

To determine whether patients can accurately identify the lung in which a cough reflex originates, a unilateral cough stimulus was administered to 67 patients during fiberoptic bronchoscopy. Although the stimulus produced a vigorous cough reflex in all subjects, 51 of 67 individuals were unable to identify the side stimulated. These results suggest that impulses from endobronchial irritant receptors are not perceived cortically as originating within a particular hemithorax.

Managing asthma and COPD in patients with cardiovascular disease

Sideris et al followed 91 patients aged 25 to 82 (mean age 55) with respiratory failure due to severe asthma, emphysema, or chronic bronchitis. They found that patients with ventricular arrhythmias were significantly older than those without them. Although arrhythmias associated with myocardial infarction are managed primarily with drug therapy, those associated with acute respiratory failure respond best to adequate oxygenation and correction of metabolic and hemodynamic abnormalities.

Value of routine daily chest x-rays in the medical intensive care unit

To ascertain the value of the daily routine chest x-ray in the medical ICU, we determined prospectively the number of unsuspected abnormalities observed on 507 consecutive chest films and the consequent management changes in 94 ICU patients. Primary diagnoses were classified as pulmonary, hemodynamically unstable cardiac, uncomplicated cardiac, or miscellaneous. Admission films and those taken after procedures or a change in clinical status were excluded. Ventilator status and the tubes and catheters visible on the films were also noted. After clinical evaluation, management plans were made by ICU physicians and then the chest x-ray was examined and unsuspected abnormalities and resulting management changes were noted. Of the 507 chest films, 76 (15%) revealed an unsuspected abnormality, 71 (93%) of which led to a management change. There were significantly (p less than .02) more unsuspected abnormalities and management changes in the pulmonary and unstable cardiac patients, independent of ventilator status. Patients with two or more catheters and/or tubes visible on the chest film also had significantly more management changes (51/312 vs. 11/150, p less than .05). We conclude that while routine chest films affect the management of pulmonary and unstable cardiac patients in the ICU, routine films rarely influence management of uncomplicated cardiac patients and those without heart or lung disease, and are not warranted in this group.

The use of labetalol for the treatment of hypertension in patients with reversible airway obstruction

Beta-adrenergic blocking agents are commonly used for the management of hypertension, cardiac arrhythmias, and angina pectoris; several of these agents are now available for clinical use (1-5). A significant side effect of these agents in patients experiencing reversible airway obstruction is that they block the effects of beta-adrenergic agonists and can precipitate or worsen bronchospasm (6-8). Labetalol, a new adrenergic antagonist with both alpha- and beta-adrenergic blocking effects, has been shown to have certain advantages for the management of hypertension and is widely used for this purpose in many countries (9). To evaluate its effects on airway resistance in patients with obstructive lung disease, the authors conducted two separate clinical studies. This article summarizes the results of these trials.

Mycobacterial, fungal, actinomycotic, and nocardial infections of the pleura

Granulomatous pleuritis is relatively common, comprising about 10 per cent of all pleural effusions. A search for the etiologic agent is important since mycobacteria, fungi, and the higher bacteria Actinomyces and Nocardia produce similar clinical, radiographic, and pleural fluid findings. The appropriate use of diagnostic tests including pleural biopsy and serologic techniques is discussed, as are current approaches to the management of these infections.

Anticholinergics, cromolyn, and other occasionally useful drugs

In asthmatics who are not controlled with beta-adrenergic agonists, theophylline and corticosteroids, the addition of anticholinergics may be beneficial. Cromolyn and the calcium-channel blocking agents are useful in preventing asthma attacks in some patients. Some other agents that have been proposed for the treatment of asthma are discussed briefly.

The spectrum and significance of pleural disease in blastomycosis

To determine the incidence and significance of pleural disease in blastomycosis, we reviewed the chest roentgenograms and medical records of 26 consecutive patients with biopsy- or culture-proved Blastomyces dermatitidis infection. Twenty-three of the 26 (88 percent) had radiographic evidence of blastomycotic pleural disease. Pleural reaction that regressed on therapy was mild (less than 1.0 cm thickening on EPA chest film) in 12. More extensive pleural thickening (1.5 to 3.0 cm) was observed in five, while four had effusions, and two had pneumothoraces. The 15 patients with mild or no visible pleural thickening were considered to have minor pleural involvement, while the 11 patients with greater than 1.5 cm pleural reaction, effusions, or pneumothoraces were considered to have major pleural disease. The ages, incidence of serious underlying disorders, and extra-thoracic dissemination were similar in both groups. Chest pain was more frequent in those with major pleural involvement (8/11 vs 4/15, p = 0.02), and their white blood cell count (14,300 +/- 1,200 c/mm3) was significantly higher than that of those with minor pleural involvement (10,600 +/- 1400, p less than 0.05). All of the patients with minor pleural disease responded to amphotericin therapy, but four of 11 (36 percent) with major pleural disease had an unfavorable outcome (relapse = two, death = two) (p = 0.02). In these patients with blastomycosis, pleural involvement was extremely common. Major pleural disease was associated with an adverse prognosis and may be an indication for prolonged therapy.

Tissue morphology of Histoplasma capsulatum in acute histoplasmosis

Reports of histopathology in acute histoplasmosis are rare. A case of fulminating acute histoplasmosis with hematogenous dissemination is described in which Histoplasma capsulatum was identified in transbronchial biopsy. This report represents the first morphologic description of H. capsulatum within human pulmonary tissue in the early phase of acute histoplasmosis. The yeast forms observed were of typical size, but they were present within the alveoli and were budding. No tissue granulomata were noted. This unusual morphology is in sharp contrast to the classic description of the organism in tissues and presented diagnostic difficulties, which are discussed in this report. Hematogenous dissemination is considered to be an important part of the pathogenesis of the disease, but it is rarely documented during the symptomatic phase of acute histoplasmosis. Cultural documentation of hematogenous dissemination was obtained in this patient. These observations stress the importance of obtaining culture material from extrapulmonary sites early in the course of acute histoplasmosis when a specific diagnosis is necessary.

Postural hypoxemia in the postpneumonectomy patient

A patient with platypnea and orthodeoxia after right pneumonectomy is described. Cardiac catheterization revealed arterial desaturation in the upright position associated with increased right to left intracardiac shunting through a patent foraman ovale. The absence of a pressure gradient between the left and right atrium in either the supine or sitting position indicated that the orthodeoxia resulted from an increase in streaming of blood from the inferior vena cava to the left atrium caused by mechanical distortion of the interatrial septum.

Some recent advances in respiratory therapy

Many changes have occurred in the field of respiratory therapy during the past few years, and further changes are likely. A number of diagnostic techniques, many of which can be performed at the bedside, are available to the therapist. New treatment modalities have been devised, and pulmonary rehabilitation is an increasing part of the therapist's responsibilities. This paper is a summary of what the authors feel are some of the significant recent changes in respiratory care, and their predictions.

Exercise capacity as a predictor of post-thoracotomy morbidity

Although severe impairment on routine pulmonary function tests will identify patients with a high post-thoracotomy morbidity, cardiopulmonary complications often develop in patients with only a mild-to-moderate impairment in pulmonary function. To determine whether the preoperative exercise capacity can prospectively identify those at risk of developing complications, 22 patients scheduled for thoracotomy (mean age, 55.7 +/- 2 yr) underwent an incremental exercise test on a cycle ergometer to determine their maximal O2 uptake (VO2max) prior to thoracotomy. Routine pulmonary function tests were performed and postoperative forced expiratory volume in one second (FEV1) was predicted from split function perfusion lung scan in all subjects. Eleven of the 22 patients had no cardiopulmonary complications postoperatively. The age, history of prior cardiovascular disease, degree of impairment on routine pulmonary function tests, and predicted postoperative FEV1 were similar in those who did and those who did not experience complications. However, those without complications had a significantly higher VO2max than did those who experienced complications (22.4 +/- 1.4 versus 14.9 +/- 0.9 ml/kg/min, p less than 0.001). Only 1 of 10 patients with a VO2max greater than 20 ml/kg/min had a complication, whereas all 6 patients with a VO2max less than 15 ml/kg/min had a complication. We conclude that exercise testing is a useful adjunct in the evaluation of operative risk for thoracotomy.

Significance of serum antibodies to Histoplasma capsulatum in endemic areas

To evaluate the specificity of serologic tests for histoplasmosis in an endemic area, we studied sera from 104 consecutive healthy blood donors, testing for antibodies to either histoplasmin or Histoplasma yeast antigen, using complement fixation (CF), radioimmunoassay (RIA), and radial immunodiffusion (ID). Twenty-five subjects (24%) had CF antibody titers of 1:8 or 1:16 to one or both antigens; none had titers above 1:16. Nine subjects (9%) had RIA antibody titers of 1:8 or higher. No titers above 1:8 were found using the yeast antigen; five subjects had titers of greater than 1:16 to histoplasmin using RIA. No precipitin bands were found in any of these subjects. The results of four previous studies in endemic populations yielded similar or lower incidences of positive tests. CF antibody titers to either antigen, RIA antibody titers to yeast antigen of 1:32 or greater, or precipitin bands are rare in persons who live where histoplasmosis is endemic.