Rheumatoid pleurisy. observations on the development of low pleural fluid pH and glucose level

A patient with rheumatoid pleurisy provided the opportunity to observe the time course of development of the low glucose level and low pH characteristic of these pleural effusions. During six days, the effusion evolved from one with a normal glucose value and pH to one with a glucose value of 20 mg/dL and a pH of 6.78. The mechanisms responsible for these phenomena probably are (1) a selective block to glucose transport from blood to pleural fluid, (2) enhanced glucose use by rheumatoid pleura, and (3) an efflux block to the end products of pleural space glucose metabolism. Once the low glucose value-low pH rheumatoid effusion develops, it seems not to revert to an effusion with a normal glucose level and pH.

The diagnostic value of pleural fluid pH

One hundred eighty-three patients had simultaneous blood and pleural fluid pH determinations. Thirty-six effusions were transudates, and 147 were exudates. In 46 effusions, the pleural fluid pH was less than 7.30; all 46 were exudates. A pleural fluid pH less than 7.30 was associated with the following six diagnoses: (1) empyema; (2) malignancy; (3) collagen vascular disease; (4) tuberculosis; (5) esophageal rupture; and (6) hemothorax. The results of pleural fluid pH determination are immediately available, narrow the differential diagnosis of the exudate, and may expedite patient management. The pH of pleural fluid should be measured whenever a diagnostic thoracocentesis is performed.

A model of immune complex-mediated pleuropulmonary injury; evidence of deposition of circulating immune complexes in the lung

Severe acute, diffuse lung inflammation was induced in rabbits immunized to bovine serum albumin (BSA) and subsequently challenged with BSA intrapleurally. Evidence suggesting involvement of circulating immune complexes in the pathogenesis of lung injury in these rabbits include 1) positive lung immunofluorescence, 2) a fall in serum hemolytic complement, 3) diffuse bilateral involvement despite unilateral antigen challenge, and 4) absence of these findings in control rabbits. Further investigation with this model may provide insight into the processes involved in the deposition of immune complexes in the lung and the mechanisms of lung injury provoked by immune complex deposition.

Incidence and outcome of the respiratory distress syndrome in gram-negative sepsis

Twenty cases of the adult respiratory distress syndrome (ARDS) in 86 cases of Gram-negative bacteremia were identified. Features of Gram-negative bacteremia associated with the development of ARDS included a history of cardiac disease, hypotension, and thrombocytopenia. The mortality of patients with and without ARDS was 90% and 55%, respectively. The association of hypotension and thrombocytopenia with the subsequent development of ARDS suggests the possible role of endotoxin-induced coagulopathy in this complication.

The pH of sclerosing agents: a determinant of pleural symphysis

The rate of success in producing pleural symphysis with intrapleural instillation of sclerosing agents has been variable. Differences in the designs of studies probably account for some of the variability, but the reasons for the remainder are not clear. Since a low pH of the pleural fluid is associated with pleural adhesions and loculations, the pH of the commonly used solutions of sclerosing agents was determined, both in their usual concentrations and when diluted with large quantities of exudative pleural fluid. The buffered solution of tetracycline hydrochloride had the most acidic pH (2.0) and showed little change when diluted by pleural fluid. A 0.5 percent solution of sodium hydroxide had the highest pH (13.0). The remainder of the sclerosing solutions showed a range of pH from 4.3 to 8.7. Experimental and clinical experience suggests that tetracycline consistently has the highest rate of success in producing pleural symphysis. It appears that when proper technique is employed, the pH of the solution of the sclerosing agent is an important determinant of the production of pleural symphysis.

Pulmonary lymphangitic carcinomatosis from the cervix. Diagnosis by transbronchial biopsy

A diagnosis of pulmonary lymphangitic spread of cervical cancer was established by transbronchial biopsy in a 58-year-old woman requiring mechanical ventilation. Confirmation of the clinical diagnosis allowed supportive therapy in this terminal stage of cancer. To our knowledge, this report is the first to describe this result from cervical carcinoma and to establish the diagnosis of lymphangitic carcinomatosis by transbronchial biopsy.

Emergency room intubations--complications and survival

Forty-three consecutive patients requiring endotracheal intubation in an emergency room were studied prospectively to define the complications associated with intubation and the survival of these patients, and to evaluate emergency room policies. The indications for intubation were acute respiratory failure (ARF) in 22 patients and cardiopulmonary arrest (CPA) in 21 patients. Thirty-eight complications occurred in 24 of the 43 patients. The department or level of training of the intubator did not affect the rate of complications. Furthermore, specific complications did not influence survival. Seventeen patients survived, all in the ARF group. Age less than 40 years and admission PaO2 greater than 40 mm Hg also were associated with increased survival. We conclude that the complication rate of emergency room intubations is high and would not appear to be lowered by limiting intubations to physicians from specific departments or with certain levels of training. The underlying diagnosis and condition on admission to the emergency room appear to be more important factors relating to survival than complications during intubation.

Moderate alcohol dose and chronic obstructive pulmonary disease: not a cause of hypoventilation

Six patients with chronic obstructive pulmonary disease (COPD) (forced expiratory volume in one second, 1.01 +/- 0.08 L [mean +/- SEM] ) were given either 1 mL of 100% alcohol per kilogram of body weight in an aqueous solution or a similar volume of water in a crossover design on consecutive days. All subjects became intoxicated and the peak alcohol concentration was 137 +/- 11 mg/dL, 40 minutes after ingestion. No significant difference was found in either PaO2 or PaCO2 between the alcohol and control period. A significant decrease in arterial pH occurred following alcohol (P less than .05), and represented a mild metabolic acidosis. Alcohol ingestion resulted in an increase in oxygen consumption (P less than .05) and carbon dioxide production (P less than .05) but no change in respiratory rate. It appears that small to moderate amounts of alcohol will not cause marked changes in oxygen tension or alveolar hypoventilation in patients with severe COPD who do not have marked hypercapnia. Nevertheless, other effects of alcohol on the cardiopulmonary system and the concomitant use of sedatives have to be considered before condoning the use of alcohol.

Cellular content of the normal rabbit pleural space

The cellular content of the pleural space of five normal rabbits was studied by three cytopreparative techniques using different methods of collection (aspiration, irrigation) and fixation (95% ethyl alcohol, 50% alcohol: 1% polyethylene glycol). The method using aspiration, 95% ethyl alcohol fixation, and the Papanicolaou stain was simple and provided the best cytologic detail. With this method 70.1% of pleural fluid cells were monocytic, 7.5% were monocytic with morphologic features typical of macrophages, 10.5% were lymphocytes, 8.9% were mesothelial cells and 1.9% were polymorphonuclear leukocytes. Other methods were technically more difficult and provided less cytologic detail. The cellular content of the normal rabbit pleural space is described, providing baseline information for the study of experimental pleural disease.

The glucose-pH relationship in parapneumonic effusions

Both a low pleural fluid glucose concentration and pleural fluid acidosis are markers of severe pleural inflammation, but the relationship between these phenomena has not been defined clearly. Therefore, we measured simultaneous pleural fluid glucose concentrations and pH in 25 consecutive parapneumonic pleural fluids. Seventeen effusions had a glucose concentration greater than 60 mg/dl (group 1, 126 +/- 7 mg/dl, mean +/- SEM), while eight had a pleural fluid glucose less than 60 mg/dl (group 2, 15 +/- 3 mg/dl, P less than .01). Pleural fluid pH was 7.35 +/- 0.03 in group 1 compared with 6.83 +/- 0.09 in group 2 (P less than .01). A significant correlation between pleural fluid glucose and pH was found (r = .81, P less than .01). Low-glucose, low-pH effusions were complicated (either loculated or empyemas). Uncomplicated effusions had glucose concentrations greater than 60 mg/dl and a pleural fluid pH greater than 7.30. The concomitant occurrence of low pleural fluid glucose and pH suggests that the mechanisms leading to these phenomena are interrelated.