Real time CT-fluoroscopy: diagnostic and therapeutic applications

The synergetic progression of CT technology and computer hardware has made ultrafast acquisition and image reconstruction possible. This has lead to the availability of CT interactive diagnosis and therapeutic procedures. Making use of our own material (337 intervention procedures during the last 17 months), we have compared our techniques and results to the recent literature data. One of the advantages of the biopsy technique is an improved sensitivity for neoplastic lesions, most certainly in cases of intrapulmonary lesions, surrounded by aerated tissue (now 94% compared to 87% in our previous study). A second advantage is the safety of the technique (only one major complication in our series). Fluid collection drainages, and more complex interventions like local injection of drugs, radio-frequency ablation, wire hook placement and ethanol injection were performed without complication. Yet another interesting feature is the shortening of the procedure time (reduced in average to an 'in-room' time of less than 30 min), which has definite economical implications. Furthermore it increases the patient's comfort and safety, and extends the scope of outpatient procedures (80% outpatient procedures in our material). On the other side the radiation exposure can be raised as an issue, especially when we consider the operator's hands. However, the described technique and the use of dedicated tools can alleviate the problem. As a conclusion, real time CT fluoroscopy has given a new input and broadens the scope of clinical indications of CT-guided diagnostic and therapeutic procedures.

Bacterial colonization of central airways after stenting

Airway stenting (AS) is increasingly used in the management of obstructive lesions of the central airways. Although retention of secretions and infection have been reported as complications of AS, the microbiological consequences of AS have not yet been evaluated. In this study, we prospectively performed protected specimen brush (PSB) sampling of the airways, before and 3 to 4 wk after AS, in 14 consecutive patients (65 +/- 17 yr), suffering from bronchial (5), extensive esophageal (2), thyroid (1), and adenocystic (1) carcinoma, stenotic tracheal burn lesions (2), postintubation stenosis (2), and Wegener's granulomatosis (1). A cutoff value of >/= 10(2) colony-forming units (cfu). ml(-)(1) was considered diagnostic for airway colonization (AC). PSB results were related to the presence and degree of secretion retention (SR) at the level of the stent. In five of the 14 patients, AC was present prior to AS; in three of these, potentially pathogenic microorganisms (PPM) were identified. After AS, AC was found in 11 (including seven patients without prior AC) of the 14 patients. In six of these patients, one or more PPM were present (Pseudomonas aeruginosa [4], Staphylococcus aureus [3], Streptococcus pneumoniae [1], Klebsiella spp. [1]). Although AC tended to be associated with the presence of SR (PSB >/= 10(2) cfu. ml(-)(1) in 10 of 12 SR-positive and in zero SR-negative cases; PSB < 10(2) cfu. ml(-)(1) in two SR-positive and in two SR-negative cases), statistical significance was not reached (Fisher exact test, p = 0.06). We conclude that AS is frequently followed by AC, the majority of which occurs in patients without AC prior to AS, and is caused by PPM. In no case, however, AC was associated with clinical signs of infection. AC tended to be associated with SR in the stent.

Systemic effects of inhaled fluticasone propionate and budesonide in adult patients with asthma

We assessed the systemic effects of budesonide (BUD) and fluticasone propionate (FP) in 23 patients with asthma, using a double-blind, placebo-controlled, double-dummy, and cross-over design. The following five treatments were given in a randomized order for 1 wk with a washout period in between of 2 wk: (1) placebo; (2) FP, 200 micrograms twice a day, inhaled from a Diskhaler; (3) FP, 1,000 micrograms twice a day, inhaled from a Diskhaler; (4) BUD, 200 micrograms twice a day, inhaled from a Turbuhaler; and (5) BUD, 800 micrograms twice a day, inhaled from a Turbuhaler. The primary variable was the area under the curve of serum cortisol versus time (AUC0-20), derived from serum samples taken every 2 h over a 20-h period following the last evening dose at 10:00 P.M. The lower doses of BUD and FLU did not cause any adrenal suppression. Compared with placebo, however, FP (1, 000 micrograms, twice daily and BUD (800 micrograms, twice daily) decreased the AUC0-20 by 34 and 16%, respectively. Fluticasone (1,000 micrograms, twice daily) was more suppressive than BUD (800 micrograms, twice daily) (p = 0.0006). The FEV1, measured the morning after the last inhalation, was significantly higher after the active treatments, compared with placebo (p < 0.02), but did not differ between all active treatments. We conclude that high doses of BUD and FP (in particular the latter), inhaled via their respective dry powder inhalers for 1 wk, result in a measurable systemic activity in patients with asthma.

Evidence of acinar airway involvement in asthma

We investigated acinar airway involvement in 20 patients with stable asthma, using the phase III slope analysis of the multiple breath N2 washout previously applied in a group of patients with COPD (Am. J. Respir. Crit. Care Med. 1998;157:1573-1577). This technique quantifies severity of conductive and acinar components of ventilation maldistribution separately, through indices S(cond) and S(acin), which increase when respective ventilation inhomogeneities increase. We also investigated the effect of salbutamol inhalation on S(cond) and S(acin) in patients with asthma and compared it with that obtained in patients with COPD. Baseline measurements in the patients with asthma show that (1) acinar ventilation inhomogeneity was indeed abnormal in patients with asthma (S(acin) = 0.195 +/- 0.026 L-1) despite the normal diffusing capacity in this group; S(acin) values were intermediate between those obtained in unaffected individuals and patients with COPD, and that (2) conductive ventilation inhomogeneity was abnormal in the patients with asthma (S(cond) = 0.076 +/- 0.006 L-1) but similar to that obtained in the patients with COPD. Measurements after salbutamol inhalations showed significant changes in S(cond) and S(acin) only in the patients with asthma (p < 0.001). This study primarily demonstrated significant, but partially reversible, acinar airway impairment in patients with asthma, as compared with the more severe baseline acinar airway impairment in patients with COPD, which was not reversible after salbutamol inhalation.

A source of experimental underestimation of aerosol bolus deposition

We examined the measurement error in inhaled and exhaled aerosol concentration resulting from the bolus delivery system when small volumes of monodisperse aerosols are inspired to different lung depths. A laser photometer that illuminated approximately 75% of the breathing path cross section recorded low inhaled bolus half-widths (42 ml) and negative deposition values for shallow bolus inhalation when the inhalation path of a 60-ml aerosol was straight and unobstructed. We attributed these results to incomplete mixing of the inhaled aerosol bolus over the breathing path cross section, on the basis of simultaneous recordings of the photometer with a particle-counter sampling from either the center or the edge of the breathing path. Inserting a 90 degrees bend into the inhaled bolus path increased the photometer measurement of inhaled bolus half-width to 57 ml and yielded positive deposition values. Dispersion, which is predominantly affected by exhaled bolus half-width, was not significantly altered by the 90 degrees bend. We conclude that aerosol bolus-delivery systems should ensure adequate mixing of the inhaled bolus to avoid error in measurement of bolus deposition.

Screw-thread vs Dumon endoprosthesis in the management of tracheal stenosis

STUDY OBJECTIVES

A frequent complication of the widely used Dumon silicone stent is its tendency to migrate when used in tracheal stenosis. We compared the clinical efficacy and complications (including migration) of the Dumon stent with a screw-thread stent, a device with an increased stent-to-wall contact surface and, theoretically, less tendency to migrate.

DESIGN

Retrospective case analysis.

SETTING

Academic hospital.

MATERIALS AND METHODS

Forty-six patients with tracheal stenoses (23 benign and 23 malignant) requiring the placement of 50 stents (29 Dumon and 21 screw-thread) were studied. In 26 patients Dumon stents were used, and in 20 patients screw-thread stents were used. Both patient groups had comparable clinical and stenosis-related characteristics.

RESULTS

Stent insertion and follow-up were uneventful in both the Dumon and the screw-thread insertions, respectively: 62% vs 67% (not significant). There were seven migrations in the Dumon group, compared to only one migration in the screw-thread group, respectively: 24% vs 5%. This difference did not reach statistical significance (p = 0.1). All of the migrations occurred in the benign stenosis group, and none occurred in the malignant-stenosis group, respectively: 8 of 23 vs 0 of 23, p = 0.004. Within the benign-stenosis group, the Dumon stent had a significantly increased risk for migration when compared to the screw-thread stent, respectively: 7 of 13 vs 1 of 11, p = 0.033.

CONCLUSIONS

The screw-thread stent and the Dumon stent are equally effective in the management of tracheal stenosis. There is a general trend toward a decreased migration rate, and a significantly lower risk for migration in patients with benign tracheal stenosis. The (less expensive) screw-thread stent may represent an attractive alternative in the management of tracheal stenosis in general, and may be preferable to the Dumon stent in treating benign tracheal stenosis.

Thoracoscopic T2-T3 sympathicolysis for essential hyperhidrosis in childhood: effects on pulmonary function

Thoracoscopic T2-T3 sympathicolysis (TS) is a minimally invasive treatment for patients suffering from severe, refractory essential hyperhidrosis (EH). TS has previously been shown to be safe and efficacious in children. In order to examine the effects of TS on respiratory function, pulmonary function tests (PFT) were performed prior to and 6 weeks and 6 months after TS in 12 children with EH (3 boys; mean age 12.8+/-2.5 years). Small asymptomatic decreases in forced expiratory volume in one second (FEV1; -2%), forced expiratory flow after expiration of 75% of vital capacity (FEF75; -9.6%), total lung capacity (TLC; -1%), transfer factor for diffusion of carbon monoxide (T(LCO); -7.6%), and transfer coefficient for diffusion of carbon monoxide (K(CO); -1.5%) were observed 6 weeks after TS. These changes are comparable to those observed in adults but did not reach statistical significance in small children. In line with observations in adults, TLC (and T(L,CO)) returned to baseline values 6 months after TS, whereas FEV1, FEF75, and K(CO) remained at their 6-week level. In conclusion, TS causes only small, statistically insignificant, and asymptomatic decreases in pulmonary function in children. TS can, therefore, be considered a safe treatment option in children suffering from severe, refractory EH.

Effect of body posture on spirometric values and upper airway obstruction indices derived from the flow-volume loop in young nonobese subjects

STUDY OBJECTIVE

To define the effect of changes in body posture on flow-volume loops (FVLs) and four commonly used indices of upper airway obstruction (UAO) in young, nonobese normal subjects.

DESIGN

Prospective comparative study.

SETTING

Pulmonary function laboratory at an academic hospital.

PARTICIPANTS

Thirty-one normal volunteers.

INTERVENTION

At least three FVLs per posture were obtained in the sitting, supine, and left and right lateral recumbent postures while maintaining a constant position of the head and neck in relation to the trunk. In each body posture, the largest observed flow rates were used to calculate the UAO indices.

RESULTS

When subjects changed from the sitting to each of the three recumbent postures, all spirometric values decreased significantly (p<0.0001). However, among the four UAO indices, only the FEV1/peak expiratory flow ratio increased significantly (although only slightly, by 2.9 and 4.4%, respectively) in both the right and left lateral recumbent postures (p<0.0001), but not in the supine posture. None of the subjects developed an inspiratory or expiratory plateau on the FVL in any of the three recumbent postures.

CONCLUSIONS

In young, nonobese normal subjects, recumbency does not induce UAO, at least not detectable by changes in the FVL configuration or in UAO indices derived from the FVL. Furthermore, the study provides the upper limits of recumbency-related changes in the various UAO indices for young, nonobese normal subjects.

Conductive and acinar lung-zone contributions to ventilation inhomogeneity in COPD

We investigated ventilation inhomogeneity in patients with chronic obstructive pulmonary disease (COPD) through use of the multiple breath N2 washout test (MBW). From an alveolar slope analysis throughout the MBW, we derived two indices, S(cond) and S(acin), as a measure of ventilation inhomogeneity in conductive and acinar zones of the lungs, respectively (J. Appl. Physiol. 1997;83:1807-1816). We evaluated the relationship of S(cond) and S(acin) to standard lung-function indices by means of a principal-components factor analysis, which linked correlated indices to independent factors accounting for 81% of the total variance within the COPD group. S(acin) was linked to the so-called acinar lung-zone factor, which also comprises diffusion capacity measurements. S(cond) was linked to the so-called conductive lung-zone factor, which also comprises specific airway conductance (S(Gaw)) and forced expiratory flows. FEV1 divided by FVC (FEV1/FVC) was the only variable linked to both the conductive and the acinar lung-zone factors. The fact that S(cond) and S(acin) were linked to independent factors provides statistical confirmation of the hypothesis that S(cond) and S(acin) reflect independent lung alterations, whereas FEV1/FVC behavior indicates a combined conductive and acinar contribution to airways obstruction.

Interventional bronchoscopy: 5-year experience at the Academic Hospital of the Vrije Universiteit Brussel (AZ-VUB)

Our experience with interventional bronchoscopic techniques in a University Hospital is described: in 93 patients during a 5-year period, 149 interventional procedures (i.e., Nd-YAG laser photoresection and/or airway stenting and/or balloon dilatation) have been performed. Laser resection was successful in relieving major symptoms (intractable dyspnea, hemoptysis or retro-obstructive complications) in 35/41 (85%) of malignant indications, and in 18/19 (94%) of benign obstructions. Major complications included one death (1.6%) early in the series, and major nonfatal hemorrhage in three patients (5%), all with malignant disease. In 31/35 (89%) of malignant central airway stenoses treated with stents, respiratory symptoms could be palliated successfully. Mean survival after stenting was 6 +/- 5.3 months. In 20/23 (87%) of benign tracheal stenoses, temporary or permanent stenting allowed for complete restoration of airway patency. The development of inexpensive and simplified insertion techniques for existing stents, and of a new (and even less expensive) type of tracheal stent has enabled the use of airway stenting in all categories of patients. Bronchoscopic balloon dilatation was helpful in the mechanical dilatation of stenoses, and in the unfolding of unopened stents. Finally, a plea for an organised referral system and for active collaboration between interventional bronchoscopy centers is made.

A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions

In comparative studies with other agents, insufflated talc has been shown to be the most effective agent in achieving chemical pleurodesis in patients with malignant pleural effusions. The objective of this study is to compare the efficacy of talc administered as slurry (5 g in 50 mL saline) via tube thoracostomy with that of bleomycin (1 mg/kg in 50 mL saline) (which is the most effective agent other than talc). In a randomised, prospective comparative study, twenty-six consecutive patients with proven malignant pleural effusions (recurrent after at least two pleuroscenteses) in whom no pleurodesis attempt had yet been made, and who were symptomatic, had a Karnovski index < or = 50, and an expected survival of one year or less, were included. Therapeutic failure was defined as recurrent pleural fluid > or = 50% of initial volume or requiring pleurocentesis. Recurrence rates (25% vs 21.4%, NS), fever (25% vs 35.7%, NS), pain (0% both groups) and survival (3.75 +/- 3 vs 5.82 +/- 7.15 months, NS) did not differ between bleomycin or talc treated patients. There were no major complications (e.g., empyema) or side-effects. In conclusion, talc slurry and bleomycin are equally effective in achieving chemical pleurodesis via thoracostomy in patients with malignant pleural effusions, and the safety profile of both agents is similar. Since talc is substantially less expensive than bleomycin, talc slurry probably represents the agent of choice for chemical tube thoracostomy pleurodesis.

Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists

Intractable pain is the most invalidating symptom in patients suffering from chronic pancreatitis. Anatomical interruption of the major afferent pain nerves is indicated in severe refractory cases. Among the various techniques and sites of interruption, thoracoscopic splanchnicectomy has emerged as an efficient alternative for the more aggressive open surgical splanchnicectomy, and for the (solely temporarily efficacious) transcutaneous neural blocks, which moreover bear some serious complications. Until now, all reports on thoracoscopic splanchnicectomy were typically surgical, using video-assisted thoracoscopic surgery techniques, double-lumen intubation, and so on. In analogy with thoracoscopic upper dorsal T2-T3 sympathicolysis for essential hyperhidrosis, a simplified thoracoscopic splanchnicolysis technique used in 8 patients suffering from either severe refractory chronic pancreatitis pain (7 patients) or postsurgical epigastric pain is described. Pain control was achieved in 5 of the 7 patients with chronic pancreatitis with a short (20+/-8 min) intervention, short hospitalization (2 days), and simple (single-lumen intubation, no chest drains) procedure. Thus, this simplified thoracoscopic splanchnicolysis technique may represent a valid alternative in the often difficult treatment of refractory chronic pancreatitis pain or other upper abdominal pain.

Ventilation distribution during histamine provocation

We investigated ventilation inhomogeneity during provocation with inhaled histamine in 20 asymptomatic nonsmoking subjects. We used N2 multiple-breath washout (MBW) to derive parameters Scond and Sacin as a measurement of ventilation inhomogeneity in conductive and acinar zones of the lungs, respectively. A 20% decrease of forced expiratory volume in 1 s (FEV1) was used to distinguish responders from nonresponders. In the responder group, average FEV1 decreased by 26%, whereas Scond increased by 390% with no significant change in Sacin. In the nonresponder group, FEV1 decreased by 11%, whereas Scond increased by 198% with no significant Sacin change. Despite the absence of change in Sacin during provocation, baseline Sacin was significantly larger in the responder vs. the nonresponder group. The main findings of our study are that during provocation large ventilation inhomogeneities occur, that the small airways affected by the provocation process are situated proximal to the acinar zone where the diffusion front stands, and that, in addition to overall decrease in airway caliber, there is inhomogeneous narrowing of parallel airways.

Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults

Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.

Effects of antihistamines in adult asthma: a meta-analysis of clinical trials

A meta-analysis of clinical trials of antihistamines was performed to assess the risk-benefit ratio of this therapeutic class in asthma. Double-blind randomized placebo-controlled trials assessing lung function changes under repeated use of antihistamine in adult asthma were selected, and the quality of studies was scored. Morning peak expiratory flow rate (PEFR) was the primary outcome: an effect size was computed for each study, with a 95% confidence interval (95% CI), and a mean effect size was computed, combining all studies. Effect sizes were also determined for secondary outcomes: evening PEFR, forced expiratory volume in one second (FEV1) and daily use of inhaled beta-agonists. Nineteen studies were included in the meta-analysis. Mean quality score of studies was 59.4%; asthma was generally uncontrolled at study inclusion. Altogether, 582 antihistamine-treated and 557 placebo-treated asthma patients were evaluable. Antihistamines had little effect on airway calibre (mean increase in morning PEFR: 13 L x min(-1); 95 CI: 8-18 L x min(-1)) and on use of inhaled beta-agonists (mean reduction in daily use: 0.4 doses; 95% CI: 0-0.8 doses). Sedation occurred more often with antihistamines than with placebo (p<0.001); additional side-effects were mentioned, including weight gain, altered taste, headache and dry mouth. Respiratory and systemic effects observed after repeated use of antihistamines do not support the use of these medications in the treatment of asthma; better designed studies could affect this appraisal.

Essential hyperhidrosis in Turner syndrome

We describe two Turner patients suffering from severe essential hyperhidrosis. Since both disorders are rare (1 in 5000 live female births for Turner syndrome and approximately 1 in 1000 persons for essential hyperhidrosis), our finding of two patients with these disorders in a total of 150 essential hyperhidrosis patients may suggest that this association is more frequent in Turner syndrome than previously thought.

Plasma catecholamine concentrations in essential hyperhidrosis and effects of thoracoscopic D2-D3 sympathicolysis

Essential hyperhidrosis (EH) is caused by a poorly understood overactivity of the sympathetic fibres passing through the upper dorsal sympathetic ganglia D2 and D3. These ganglia are also in the pathway of the sympathetic innervation of the heart and lungs. Therefore, although the predominant sympathetic neurotransmitter at the eccrine sweat glands is acetylcholine, the plasma concentration of noradrenaline (NA) (which is the main sympathetic neurotransmitter at the end organs including the heart and the lungs) may be elevated. Furthermore, as there are some indications for generalized sympathetic overactivity in EH, the plasma concentration of adrenaline (A) may also be elevated. Plasma levels of NA and A were therefore determined in 13 EH patients before and after thoracoscopic D2-D3 sympathicolysis (TS). Preoperative NA and A plasma levels were all within the normal limits used in our laboratory. After TS, mean NA plasma levels are significantly decreased, whereas mean A are unchanged. We conclude that sympathetic overactivity in EH is limited to the upper dorsal sympathetic ganglia and that some of the cardiovascular and pulmonary effects that are observed after TS may be associated with the decrease in NA.

Comparison of video-assisted thoracoscopic talcage for recurrent primary versus persistent secondary spontaneous pneumothorax

Thoracoscopic talcage (TT) is a safe and effective prophylactic treatment for patients suffering from recurrent primary spontaneous pneumothorax (PSP). Empirically, TT is considered equally effective in the treatment of persistent secondary spontaneous pneumothorax (SSP), although this has not yet been proved. In this study, the efficacy and safety of TT was prospectively evaluated in 28 patients (17 males and 11 females, mean age 27 +/- 8 yrs), with 31 episodes of recurrent PSP, and in 20 patients (13 males and 7 females, mean age 43 +/- 21 yrs) with persistent SSP. TT proved to be equally effective in achieving pleurodesis in both groups; there were 6.5% recurrences in the PSP group and 8.7% in the SSP group during a mean follow-up period of 18 months (p > 0.05). In the SSP group, there were significantly more prolonged postoperative air leaks (26 vs 0%; p = 0.004) and a longer postoperative chest tube drainage time (35.5 +/- 18 vs 24.9 +/- 3.2 hrs; p = 0.002) was necessary. All air leaks, however, ceased spontaneously during drainage. Duration of hospitalization was significantly longer in the SSP group (4.7 +/- 2 vs 3.2 +/- 0.5 days; p < 0.0001). Postoperative pain (90 vs 43%; p < 0.0001) and fever (65 vs 17%; p = 0.001) were more frequent in the PSP group than in the SSP group. There were no major peri- or postoperative complications in either group. We conclude that thoracoscopic talcage is as efficient and safe in achieving pleurodesis in persistent spontaneous pnuemothorax as in recurrent primary spontaneous pneumothorax.

Assessing asthma management from interviews of patients and family physicians

Directed self-care is recommended in asthma. Adequate patient education and follow-up are nevertheless necessary to optimize outcomes. We compared the agreement between detailed information on asthma history and management, collected from the patient and the family physician, to validate the files of physicians and to assess patients' knowledge, attitude, and behavior concerning asthma. A sample of 54 asthma patients were interviewed in detail about use of medications and self-care practice; 36 family physicians (FPs) were interviewed concerning asthma therapy, history, and attitudes of the same patients. Forty-eight percent of the patients expressed negative attitudes toward inhaled corticosteroids, for reasons of safety or lack of efficacy. Less than 20% of the patients made regular use of a peak flow meter. Eighty-three percent of the patients usually obtained prescriptions for asthma therapy from their FP, but on average, only 40% of these prescriptions were provided during visits specific to asthma. FPs were not optimally informed of actual treatments and outcomes and had poor perception of patients' attitudes toward treatment. Nonetheless, in about 30% of the patients, FPs identified risk factors for adverse outcome, such as depression and family conflicts. A majority of interviewed patients had a negative perception of anti-inflammatory therapy, specifically relating to issues of safety and efficacy. Peak flow meters were seldom used and therapy was commonly prescribed outside visits specific to asthma. Despite being centrally involved in the care of asthma patients, FP did not optimally assess therapy and outcomes. The findings suggest suboptimal education and health status in this asthma population.

Severe community-acquired pneumonia caused by atypical organisms

Three cases of community-acquired pneumonia (CAP), requiring intensive care admission, are presented. The clinical picture of a "typical" bacterial pneumonia in the three patients led to an initial empirical treatment with amoxicillin clavulanic acid or 2(nd) generation cephalosporins. The treatment had to be changed in all three because of clinical failure. Erythromycin was added to the therapy with good clinical evolution. Serology confirmed atypical organisms to be responsible. Only the chest X-ray might have suggested an "atypical" or a "viral-like" agent. A proposition is made for an empirical combination of antibiotics in severely ill patients with CAP with more than unilobar consolidation.

Actual use of inhaled corticosteroids and risk of hospitalisation: a case-control study

BACKGROUND

The relationship between therapy and adverse outcome in asthma is debated especially for naturally occurring situations. This is due in part to insufficient information regarding actual use of medications.

OBJECTIVE

This study was conducted to clarify the relationship between actual intake of anti-asthma drugs and asthma hospitalisation, considered as an outcome.

METHODS

A case-control study was performed. Patients hospitalised for an asthma exacerbation were matched to community controls identified in surrounding general practices. Patients were questioned to identify prior use of anti-asthma medications, level of use of inhaled corticosteroids and attitude towards therapy.

RESULTS

Twenty-three cases and 31 matched controls were interviewed. Cases tended to have more severe asthma than controls, as judged by more frequent use of oral corticosteroids. Cases tended to make more frequent use of oral xanthines and inhaled anticholinergics, but the proportion of patients using inhaled beta 2-adrenoceptor agonists and inhaled corticosteroids was similar in both groups. Use of lower doses of inhaled corticosteroids was associated with an increased risk of hospitalisation, while higher dosage was associated with decreased risk. Cases and controls differed as to their answers to a questionnaire concerning attitudes: cases expressed less interest in optimal usage of inhaled corticosteroids than controls; they also expressed more confidence in inhaled beta 2-agonists. When both risks were combined, overconfidence in beta 2-agonists and suboptimal use of inhaled steroids, the relationship with hospitalisation was significant (OR 5.5, 95% CI 1.1; 26.1).

CONCLUSION

The results suggest that patients' attitudes to inhaled corticosteroids and actual consumption of these medications are directly related to adverse outcome in asthma.

Effect of posture on the flow-volume loop in two patients with euthyroid goiter

In two patients with a goiter and respiratory symptoms occurring only in the recumbent posture, flow-volume loops (FVLs) were performed in various body postures: while sitting upright, supine, and left and right lateral decubitus. In both patients, flow rates, upper airway obstruction indices, and FVL morphologic features with patients in recumbent postures indicated the appearance of upper airway flow limitation with patients in the recumbent posture as compared with the upright posture. In the one patient who underwent thyroid surgery, these posture-related changes disappeared. We conclude that in patients with a goiter (or any extrinsic mass near to the upper airway), the comparison of FVLs performed in various body positions may help to clarify the origin of posture-related respiratory symptoms.