Corticosteroids in chronic bronchitis and pulmonary emphysema

Chronic bronchitis and emphysema (chronic obstructive pulmonary disease [COPD]) represent a major health problem in this country. Corticosteroids have provided an important advance in the management of bronchial asthma, but the role of these drugs in the therapy for COPD has not been defined clearly. To gain further insight into this problem, an overview of the pharmacologic properties and mechanisms of action of corticosteroids on the cellular systems of the lung and a critical analysis of the 17 studies evaluating the efficacy of therapy with corticosteroids in COPD were done. There are several theoretic reasons why corticosteroids might be useful in treating COPD; however the majority of studies have not demonstrated a positive effect, yet individual patients have attained marked improvement. An objectively monitored, finite trial of therapy with corticosteroids in the patient with COPD who has worsening symptoms is warranted, as the benefit is high in responsive individuals and the risk is low in nonresponders.

Effect of aminophylline on ventilatory responses in normal man

The bronchodilator effects of aminophylline have been well documented but its effect on ventilatory drives has not been systematically evaluated. Accordingly, the ventilatory responses to hypoxia and to hypercapnia were measured before and after the intravenous administration of 5 mg of aminophylline per kg of body weight to 6 normal subjects. Hypoxic ventilatory response, as measured by an index of the relation between ventilation and hypoxia (parameter A) increased from a mean +/- SE control value of 146 +/- 25 to 254 +/- 35 75 min after the infusion (P less than 0.05). Significant increases in A were also noticed immediately after and 35 and 50 min after the aminophylline infusion. Oxygen consumption increased from a control value of 235 +/- 21 to 263 +/- 21 ml per min STPD (P less than 0.03), and CO2 production increased from 184 +/- 12 to 202 +/- 13 ml per min STPD (P less than 0.01) after aminophylline. Hypercapnic ventilatory response, measured as the slope of the ventilatory response to hypercapnia, was not altered after the aminophylline. Thus, in addition to bronchodilation, the augmentation of the ventilatory response to hypoxia may be a useful factor when this drug is used in acute respiratory failure secondary to airway obstruction.

Tuberculous pneumonia with the syndrome of inappropriate secretion of antidiuretic hormone: cause of the adult respiratory distress syndrome

Bilateral tuberculous pneumonia with the syndrome of inappropriate secretion of antidiuretic hormone was the cause of the adult respiratory distress syndrome in an elderly patient. Early recognition and prompt therapy enabled the patient to make a complete recovery without the necessity for mechanical ventilation. With the shift of care of tuberculous patients out of the sanitorium, the practicing physician should be aware of the varied manifestations of tuberculosis.

Effects of hypermetabolism on ventilation and chemosensitivity

Muscular exercise is associated with hypermetabolism and increased hypoxic ventilatory response (HVR). In order to dissociate mechanical and metabolic factors, the effect of hypermetabolism on hypoxic ventilatory response was evaluated at rest. Carbohydrate and protein feeding increases metabolic rate, and their effects on chemosensitivity, ventilation, and blood pH were evaluated in six normal subjects 2 h and 3 h after calorically equal test meals (1,000 cal). After carbohydrate, base-line oxygen consumption (Vo(2)) increased from 237+/-11.3 ml/min (SEM) to 302+/-19.4 (P < 0.001) and 303+/-18.5 (P < 0.001) at 2 h and 3 h, respectively. Hypoxic ventilatory response, measured as shape parameter A, increased from a control of 144+/-11.8 to 330+/-61.0 (P < 0.01) at 2 h and 286+/-57.0 (P < 0.05) at 3 h. These changes were associated with a mild metabolic acidosis as pH decreased from a control of 7.402+/-0.004 to 7.371+/-0.009 (P < 0.005) at 2 h and 7.377+/-0.008 (P < 0.005) at 3 h. After protein, Vo(2) increased from 241+/-6.7 to 265+/-6.2 (P < 0.02) and 270+/-5.4 (P < 0.001), an overall increase less than that which occurred after carbohydrate (P < 0.01). Hypoxic ventilatory response increased from 105+/-14.5 to 198+/-24.3 (P < 0.02) at 2 h and 219+/-17.3 (P < 0.01) at 3 h, which was not different from the increase with carbohydrate. After protein, no acidosis occurred. Thus, after protein, HVR increased despite the absence of a systemic acidosis. We conclude that both carbohydrate and protein feedings are associated with resting hypermetabolism and increased HVR compared with the fasting state. For both meals, increased metabolic rate was correlated with increased hypoxic response.

Status asthmaticus. A nine-year experience

A retrospective analysis of 811 patients admitted to the hospital for status asthmaticus over a nine-year period was performed. Eight patients died, and 19 required mechanical ventilation. All persons who died of status asthmaticus were in the group that required mechanical ventilation. In 12 of the patients who received ventilation, no definite cause for the acute exacerbation could be identified, although initial arterial blood gas analyses showed profound hypoxemia, hypercapnia, and acute respiratory acidosis. Seventy-eight major complications occurred during mechanical ventilation. Pneumothorax, endotracheal tube malfunction, alveolar hypoventilation on the ventilator, and pneumonia were associated with decreased survival. Mucous plugging of the airways was found in all autopsied patients. Mechanical ventilation in status asthmaticus is a life-support system associated with substantial morbidity and should be instituted only when it becomes evident that maximal medical therapy will not be efficacious.

Pleural fluid pH in parapneumonic effusions

The pH and carbon dioxide tension were measured in 24 consecutive parapneumonic effusions, along with the leukocyte count, leukocytic differential count, and levels of glucose and protein. Three categories of parapneumonic effusions were characterized: (1) empyemas; (2) benign (nonloculated) effusions; and (3) loculated effusions. A pH greater than 7.30 was present in all ten benign effusions, and spontaneous resolution occurred in each case. All ten empyemas and the four loculated effusions had a pH less than 7.30. All four loculated effusions required drainage with a chest tube for resolution. The pH of the pleural fluid alone separated the empyemas and loculated effusions from benign effusions. The early separation of parapneumonic effusions on the basis of the pleural fluid appears useful. If the pH is greater than 7.30, a benign effusion is present, and spontaneous resolution is likely. If the pH is less than 7.30, loculation of the pleural space may occur regardless of whether the effusion fulfills the criteria for empyema.

Effect of diazepam on ventilatory responses

To investigate the effects of diazepam on ventilatroy control, hypoxic and hypercapnic ventilatory responses were studied in 8 normal subjects before and after 10 mg of intramuscular diazepam. There was no significant change in either resting minute ventilation or resting end-tidal CO2 tension, but depression of hypoxic ventilatory response was observed 15 (60% of control) and 30 min (53% of control) after diazepam (p less than 0.05). No significant depression of hypercapnic ventilatory response was noted 70 to 130 min after diazepam. In view of the depression of hypoxic ventilatory response by diazepam in normal subjects, adverse responses along these lines should be considered in patients with impaired ventilatory function, such as chronic airways obstruction, and in those encountering acute hypoxemia.

Tuberculosis after corticosteroid therapy

Fourteen episodes of reactivation of tuberculosis after corticosteroid administration are reported. In most a disease impairing the host defences was present and four were taking additional immunosuppressants. The most common presenting symptoms were productive cough and malaise. Bacteriological diagnosis required bronchoscopy in three cases. Response to antituberculosis therapy was good. Five of the 14 episodes manifested dissemination of pulmonary tuberculosis with four occurring in patients receiving high-dose corticosteroids and other immunosuppressants. No prolongation of sputum conversion time was noted in the patients. The published effects of corticosteroids on the tuberculous state are reviewed. Because INH administration may cause liver damage in a small minority of patients, a reassessment is required of the need for INH chemoprophylaxis when corticosteroids are used in patients with healed tuberculosis.

Abdominal manifestations of pulmonary embolism

The cardiopulmonary manifestations of acute pulmonary embolism are well known. However, abdominal manifestations of thromboembolic disease are less well appreciated. We recently encountered three patients with pulmonary emboli who also had complications of abdominal signs and symptoms. Two patients initially had abdominal complaints that obscured the diagnosis. In the other patient, symptoms and signs developed that were indistinguishable from an acute surgical condition of the abdomen after the diagnosis of massive pulmonary embolism was established. Abdominal manifestations alone may be the presenting features of pulmonary embolism or may complicate the clinical course.

Pleural mesotheliomas--an analysis of 18 cases and review of the literature

Eighteen cases of mesothelioma, 7 benign and 11 malignant, were analyzed retrospectively. There were 5 females with benign tumors and 10 males with the malignant variety. The mean age was 59 years in the benign group and 55 years in those with malignant tumors. Exposure to asbestos was documented in one benign and five malignant mesotheliomas. Three patients with benign lesions were asymptomatic on presentation while all 11 with malignant tumors had symptoms, chest pain and dyspnea being the most frequent. Abnormal physical findings were rarely noted in the benign group while all the malignant tumors had abnormal findings on presentation. Signs of a pleural effusion were the most common abnormal physical findings, occurring in 8 of 11 patients. Pleural effusion was the most common roentgenologic finding in malignant mesotheliomas, while a mass lesion was the presenting finding in six of seven of the benign group. Pleural effusion was a usual accompaniment of malignant tumors and was an exudate, usually hemorrhagic with leukocyte counts up to 20,000/mm3. Thoracotomy established the diagnosis in each of the five benign and seven malignant cases in which it was attempted. Pleural biopsy was diagnostic in three of six with malignant and one of two with benign tumors. Pleural fluid cytology did not yield a diagnosis in the seven instances in which it was studied. Excisional surgery was performed in five of the benign cases and all have survived one to six years. No treatment was curative of malignant mesotheliomas. Ten of the 11 with malignant tumors died from 3 to 24 months after onset of symptoms (mean 9.9 months). The clinical features of 82 benign and 160 malignant mesotheliomas from selected series in the literature are reviewed and compared with the present series. The roentgenographic features of 51 benign and 87 malignant tumors are also presented. The clinical and diagnostic features which help differentiate mesotheliomas from bronchogenic carcinomas are discussed. A careful approach to the diagnosis of malignant mesotheliomas may help avoid an unnecessary thoracotomy.

Wegener granulomatosis with aphasia

Wegener granulomatosis, a necrotizing granulomatous vasculitis that characteristically involves the respiratory tract and the kidneys, may affect the nervous system. Despite the relative frequency of neurologic manifestations, there has not been a single report of Wegener granulomatosis manifesting as a cerebral vascular accident. Our patient had limited Wegener granulomatosis with aphasia as the symptom that was observed first. A dramatic recovery occurred after corticosteriod and cytotoxic therapy.

Fiberoptic bronchoscopy in bronchial asthma. A word of caution

Three instances of intense laryngospasm and bronchospasm occurred as a result of fiberoptic bronchoscopic examination in three patients with quiescent bronchial asthma. The indications for the procedure were hemoptysis in one patient and lobar collapse in two. It is likely that vagally mediated reflex laryngospasm and bronchoconstriction occur when irritant receptors are mechanically stimulated by the bronchoscope. Therefore, in the asthmatic population with its increased airway reactivity, indications for fiberoptic bronchoscopy should be absolute, and the procedure should be performed under optimal conditions. A rationale for minimizing the risk of this procedure in patients with bronchial asthma is discussed.

Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature

Interstitial pneumonitis may be the presenting manifestation of polymyositis-dermatomyositis, or may occur later in the evolution of the disease. The clinical picture is characterized by non-productive cough, dyspnea and hypoxemia. The chest radiograph demonstrates interstitial infiltrates with predilection for the lung bases, often with an alveolar pattern in addition. The histopathologic features are those of organizing and interstitial pneumonitis and pleuritis, with variable fibrosis. In the present series, the patients with mixed alveolar and interstitial infiltrates on chest radiograph and organizing pneumonia and bronchiolitis obliterans in addition to interstitial pneumonitis. In one patient evolution from pulmonary inflammation to interstitial fibrosis was demonstrated. The etiology of primary lung disease in PM-DM is not known, but cell-mediated autoimmunity to an unidentified component of lung tissue is suggested. Including the present series, 50 percent of patients have responded favorably to corticosteroids with decreased dyspnea, clearing of the chest radiograph and improved pulmonary function tests.

Pulmonary manifestations of systemic lupus erythematosus: review of twelve cases of acute lupus pneumonitis

Acute lupus pneumonitis was the presenting manifestation of systemic lupus erythematosus in six of 12 cases in this series. The clinical picture was characterized by severe dyspnea, tachypnea, fever and arterial hypoxemia. Radiographic findings included an acinar filling pattern which was invariably found in the lower lobes and was bilateral in 10 of the cases. Studies failed to reveal evidence of infection as a cause of the acute pulmonary infiltrates. All patients were treated with oxygen and corticosteroids; seven received azathioprine. Six patients survived and are clinically well 14 months to four years following their acute illness. Three of these patients have residual interstitial infiltrates with persistent pulmonary function test abnormalities indicating progression to chronic interstitial pneumonitis. Histologic sections of the lungs available from four patients revealed hyaline membranes and interstitial edema (four cases), acute alveolitis (two cases), arteriolar thrombosis (one case) and a prominent lymphocytic interstitial pneumonitis with organizing bronchiolitis (one case).

Intensive respiratory care unit. Review of ten years' experience

In ten years' experience in the respiratory care units serving both medical and surgical patients, 18,077 consecutive patients received ventilatory support for 24 hours or more. The overall survival rate including all patients was 75.2%. Survival rate has not changed appreciably during the past five years. The respiratory care unit provides technical assistance and consultation to primary physicians of the medical and surgical services. This system of intensive respiratory care is flexible and applicable to general hospitals that treat large numbers of patients with acute respiratory respiratory failure.

Effect of ethanol on the ventilatory responses to oxygen and carbon dioxide in man

1. Hypoxic and hypercapnic ventilatory drives were measured in eight healthy male subjects before and after ingestion of ethanol, in a dose of 17 mmol/kg body weight. 2. A significant decrease in hypoxic ventilatory drive was observed at 20 min after ethanol (P less than 0.05). A significant depression in hypercapnic drive was observed at 70 min after indigestion of ethanol (P less than 0.05). The mean peak blood ethanol (24mmol/1) occurred at 20 min, at which time the lowest mean hypoxic drive was recorded. 3. Ethanol in moderate doses produced a depression of both hypoxic and hypercapnic ventilatory drives in normal subjects. This suggests that ethanol may play a role in the precipitation of acute respiratory failure in certain patients in whom the ventilatory drive is already impaired, as in chronic airways obstruction.