Ultrasound-guided lumbar selective nerve root block plus T12 paravertebral and sacral plexus block for hip and knee arthroplasty: Three case reports

RATIONALE

For hip or knee arthroplasty, it is essential to develop a satisfied peripheral nerve block method that will benefit elderly patients or patients who are contraindicated to neuraxial anesthesia.

PATIENTS CONCERNS

Patient in Case 1 suffered from the right intertrochanteric fracture, combined with chronic obstructive pulmonary disease; Patient in Case 2 suffered from hip osteoarthritis; combined with ankylosing spondylitis; Patient in Case 3 suffered from rheumatoid arthritis, combined with ischemic encephalopathy.

DIAGNOSIS

Case 1: Right intertrochanteric fracture, chronic obstructive pulmonary disease. Case 2: hip osteoarthritis. Case 3: rheumatoid arthritis.

INTERVENTIONS

Ultrasound-guided lumbar selective nerve root block (SNRB) plus T12 paravertebral and sacral plexus block were performed in 2 patients who received hip arthroplasty and 1 patient who received knee arthroplasty.

OUTCOMES

All patients successfully received surgeries with this peripheral nerve block method and no postoperative complication was reported.

LESSONS

Ultrasound-guided lumbar SNRB plus T12 paravertebral and sacral plexus block not only satisfied the analgesia requirement of surgery, but also reduced the consumption of local anesthetic.

Substantial Increases Occur in Serum Activins and Follistatin during Lung Transplantation

Background

Lung transplantation exposes the donated lung to a period of anoxia. Re-establishing the circulation after ischemia stimulates inflammation causing organ damage. Since our published data established that activin A is a key pro-inflammatory cytokine, we assessed the roles of activin A and B, and their binding protein, follistatin, in patients undergoing lung transplantation.

Methods

Sera from 46 patients participating in a published study of remote ischemia conditioning in lung transplantation were used. Serum activin A and B, follistatin and 11 other cytokines were measured in samples taken immediately after anaesthesia induction, after remote ischemia conditioning or sham treatment undertaken just prior to allograft reperfusion and during the subsequent 24 hours.

Results

Substantial increases in serum activin A, B and follistatin occurred after the baseline sample, taken before anaesthesia induction and peaked immediately after the remote ischemia conditioning/sham treatment. The levels remained elevated 15 minutes after lung transplantation declining thereafter reaching baseline 2 hours post-transplant. Activin B and follistatin concentrations were lower in patients receiving remote ischemia conditioning compared to sham treated patients but the magnitude of the decrease did not correlate with early transplant outcomes.

Conclusions

We propose that the increases in the serum activin A, B and follistatin result from a combination of factors; the acute phase response, the reperfusion response and the use of heparin-based anti-coagulants.

Preoperative spirometry and perioperative drug therapy in patients with obstructive pulmonary dysfunction

OBJECTIVE

The presence and severity of obstructive pulmonary diseases is important determinants of non-fatal and fatal postoperative complications. This study examined the characteristics of patients in need of perioperative drug therapy for obstructive pulmonary dysfunction.

METHODS

Among 2,358 surgical patients who, between September 2009 and February 2010, underwent spirometry at the Tokai University Hospital, the 333 whose forced expiratory volume in 1 second (FEV1) / forced vital capacity ratio was <0.7 were studied retrospectively. Single and multiple variable logistic regression analyses were performed in search of predictors of need for drug therapy.

RESULTS

Among the 230 men and 103 women (mean age = 68 ± 11 years) with obstructive pulmonary dysfunction, 108 (32%) received perioperative drug therapy with bronchodilators, inhaled corticosteroids or both. By multiple variable analysis, perioperative drug therapy was significantly correlated with a history of asthma and ever smoking, cough or sputum production, FEV1 <50% predicted, and emphysema, independently of consultations with pulmonologists. In a decision tree analysis, FEV1 and smoking history were the independent predictors of perioperative drug therapy.

CONCLUSIONS

Composite assessment of clinical history, respiratory symptoms, and pulmonary function is necessary for the efficient screening of the subjects who require perioperative drug therapy for obstructive pulmonary dysfunction.

[Bullectomy of giant bullae gave significant improvement of lung function]

A 49-year-old male smoker experienced acute deterioration of a progressive breathlessness. Spontaneous pneumothorax was diagnosed, and drainage was applied. Subsequent computed tomography revealed severe bilateral emphysematous bullae with right-sided predominance, and basal atelectasis. A lung function test showed severe obstructive disease. Right-sided bullectomy was performed through anterior thoracotomy with removal of giant bullae. Postoperative examination revealed markedly improved lung function and expansion of right-sided, previously consolidated lung tissue.

[Diode laser therapy for endobronchial malignant melanoma metastasis leading bilateral main bronchus obstruction]

Bronchoscopically detected endobronchial metastases of tracheal or bronchial wall were very rare and prevalence of these lesions were about 2%. Breast, renal and colon carcinomas were the most common cancers causing endobronchial metastasis. Also some other tumors can also make endobronchial metastasis. These tumors can be listed as thyroid, ovary, parotis, maxillary, bone, nasopharynx, prostate, bladder, uterus, plasmocytoma, melanoma, testicular and sarcoma. Malignant melanomas develop by the malign transformation of the melanocytes and constitutes 4% of the skin cancers. Malignant melanoma mainly metastasis to regional lymph nodes, bones and central nervous system. On the other hand, lungs are also one of the metastasis areas of these tumors. Lung metastases usually occur by tumor emboli arriving to the pulmonary arteries. Bronchoscopically detected endobronchial metastases of malign melanoma cases are very rare. Endobronchial treatment with diode laser and rigid bronchoscopy was applied to our case which presented with left total atelectasis and endobronchial metastase in the entrance of right main bronchus. As known, Nd YAG and Nd-YAP lasers have been in use for a long time and their efficiency have been approved in endobronchial treatment. On the other hand, although diode laser has been safely used in urology, dermatology and endovasculer surgery, its role in the therapeutic bronchoscopy is new and limited. Our case is presented as an example of a rarely seen endobronchial metastasis and as an example of its management with a new device.

Idiopathic localized bronchostenosis in an adult man with frequent recurring pneumonia

The case of a 48-year-old Japanese man with idiopathic bronchostenosis in the right lower lobe is reported. The patient had fourteen episodes of pneumonia in two years and therefore surgical resection of the right lower lobe was performed for both diagnosis and treatment. Histopathology demonstrated no evidence of malignancy, tuberculosis, sarcoidosis or amyloid deposition. Despite an exhaustive evaluation, a specific etiology was never determined. The patient was given the diagnosis of acquired idiopathic localized bronchostenosis with frequent recurrence of pneumonia.

Effect and Duration of Lung Volume Reduction Surgery: Mid-Term Results of the Brompton Trial

Although many studies have reported improvement in lung function following LVRS, the magnitude of improvement and subsequent decline has not been evaluated against medical therapy after the second year.

METHODS

Existing pulmonary function records were collapsed for ech participant since randomisation from Brompton LVRS trial cohort. Longitudinal data analysis was used to profile th history of medically treated patients and the effect of LVRS.

RESULTS

Pulmonary function results were collated from survivors over a median of 25 (17 to 39) months. The estimated immediate increase in mean FEV1, following surgery was +0.2591 (0.179, 0.339), with a rate of change of -0.0051 (-0.009, -0.001) per month compared to medical therapy (p < 0.001). The changes in the secondary outcome measures (LVRS compared to medical therapy) were an increase in FVC (p = 0.004), decrease in RV (p < 0.001) and TLC (p < 0.001), with differences that were maintained over time. The initial reduction in RV/TLC ration was sustained (p < 0.001), but the estimated initial increase in peak flow was accompanied by a gradual decline that was not statistically significant (p = 0.062). KCOc showed no immediate change, but there was a gradual sustained increase with time (p = 0.009). Mean oxygen saturations improved and continued to do so compared to patients on medical therapy (p = 0.001).

CONCLUSIONS

The immediate increase in FEV1 is not sustained, although the mechanical improvements of LVRS on increasing FVC, reducing both the RV and RV/TLC ratio, appear to be maintained. The important benefits of LVRS may be the gradual and sustained increase in transfer factor accompanied by improved oxygen saturations.

[Bronchial blocking with a balloon wedge pressure Catheter in a small infant]

The need for one-lung ventilation has been increasing even in pediatric patients. However, the trachea is so narrow in pediatric patients that ordinary double-lumen tubes can not be used and there have been many reports on devices or measures to block one lung. We report our experience with a female infant weighing 2 kg who had severe chronic lung disease under mechanical ventilation, and underwent left lung lower lobectomy with one-lung ventilation technique. We chose a balloon wedge pressure catheter to block the left main bronchus, because it has a central lumen through which a guide wire can be passed and sucking is available. The infant was in need of continuous ventilation and the catheter was too soft to be inserted directly. We first inserted an 18G catheter of a needle-catheter assemble outside the tracheal tube through which a guide wire was inserted into the left main bronchus with the aid of direct vision of a 2-mm fiberoptic bronchoscope through the tracheal tube, and then inserted the balloon wedge pressure catheter placing it in an appropriate position. One-lung ventilation was successfully achieved and the operative and postoperative course was uneventful.

Anomalous origin of a pulmonary artery from the ascending aorta: surgical repair resolving pulmonary arterial hypertension

OBJECTIVE

To emphasize the diagnostic possibility of the anomalous origin of one pulmonary artery from the ascending aorta in infants with clinically refractory heart failure and no intracardiac structural defect.

METHODS

Retrospective study of 4 infants with refractory heart failure undergoing 2-dimensional echocardiographic study with subcostal, suprasternal, and parasternal views, and hemodynamic and angiocardiographic study in the anteroposterior projection.

RESULTS

Three of the 4 infants had their right pulmonary artery originating from the ascending aorta as their major diagnosis. In the fourth patient, the left pulmonary artery originated from the ascending aorta in association with a large interventricular septal defect. The pressure level in both pulmonary arteries in all infants was that of the systemic level. All patients underwent surgery, which consisted of translocation of the anomalous pulmonary artery from the aorta. Neither immediate nor late cardiac deaths occurred.

CONCLUSION

Once the diagnosis of anomalous origin of the pulmonary artery from the ascending aorta in the isolated form is established, the surgical correction should be immediately performed, not only because of the risk of developing pulmonary vascular disease, but also because of the excellent surgical results currently obtained.

Assessment and management of patients with pulmonary disease

OBJECTIVE

Often, the critically ill are not optimized in terms of their chronic diseases and are with little physiologic reserves.

DATA SOURCES

This article contains a review of the pathophysiology of the major preexisting and chronic pulmonary disease encountered in the critically ill, such as asthma, emphysematous disease, and chronic bronchitis. It also includes a summary of other significant disease processes such as acute respiratory disease syndrome, cigarette smoking, and pulmonary alveolar proteinosis and the implications of obesity and obstructive sleep apnea. When confronted with critical illness, the morbidity is magnified. Close observation of patients for evidence that the underlying disease may complicate their pulmonary status, and vice versa, creates an environment where the whole patient can heal and recover from illness.

CONCLUSION

The aim of the intensive care unit team should be recognition of the patient at risk, use of necessary therapies (i.e., bronchodilators) as early as feasible, and treatment titrated to realistic endpoints as the acute illness progresses and subsequently resolves.

[Surgical aspects of non-respiratory activity of the lungs during acute pyonecrotizing diseases]

The preoperative preparation program based upon the experience of treating 465 patients with acute pyonecrotizing diseases of lungs was developed. This system takes into account the stage of the disease (I--septic, II--stabilization, III--remission), endotoxicosis intensity and non respiratory activity of the affected lung (NRAL). The patients of the first group (I stage of the disease) with long-term subclavian vein catheterization were on the special scheme of NRAL correction, their supurative focuses being treated with electrized hypochlorite sodium solution. The system appeared to be effective in managing patients, in the first group--254 patients of which 202 (79,9%) were successfully treated without operation, as for the second group, there were only 52 (40,6%), in the third--26 (31,3%). By limiting and stabilizing the process, the effect of this preoperative preparation program was also seen in other patients. It allowed to perform less traumatic operations (lung resection) in 109 patients of the 179 operated on, with 8,7% of postoperative complications in 8,7% in the first group vers. 18,4% and 24,6% in the second and third, respectively. Thus the above mentioned results show the proposed system to be effective.

Management of COPD: surgical options

Dyspnoea on exertion and exercise intolerance are the hallmarks of chronic obstructive pulmonary disease (COPD); the primary causes appear to be respectively, increased airway resistance with reduced maximal ventilatory capacity and peripheral skeletal muscle dysfunction with early onset of anaerobic metabolism. Patients with end-stage COPD usually show little or no benefit from conventional medical treatment. Physical training is capable of ameliorating exercise tolerance, but improvement is usually modest in the advanced disease state. Two surgical options are generally accepted for carefully selected patients with emphysema: resection of large bullae, when identified, and lung transplantation. Transplantation, the only effective cure for advanced COPD, is of limited use primarily because of age, comorbidity, limited availability of organs and cost. A different approach for severe emphysema, lung volume reduction surgery (LVRS), has been increasingly utilized during the past several years. In carefully selected emphysematous patients, LVRS improves lung volumes and mechanics, and reduces exertional dyspnoea. Unfortunately, surgical mortality still remains high and some patients show no measurable improvement after surgery. There is an urgent need for data on long-term effects of LVRS; the results of large, randomized trials will soon be forthcoming. The aim of this brief review is to summarize the available knowledge on the effects of LVRS, the criteria for patient selection, short- versus long-term effects and, finally, to propose future directions in this field.

Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary end-points

BACKGROUND

The appropriate age to perform bilateral, sequential lung transplants (BSLT) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Although single lung transplant (SLT) offers an advantage in terms of organ availability, the long-term survival may not warrant this strategy in all age groups.

METHODS

We analyzed 2,260 lung transplant recipients (1835 SLT, 425 BSLT) with COPD recorded in the International Society for Heart and Lung Transplantation/United Network for Organ Sharing thoracic registry between January 1991 and December 1997. To assess mortality, we performed univariate (Kaplan-Meier method and the chi-square statistic) and multivariate analyses (proportional hazards method). Because of incomplete morbidity data in the international registry, only data from U.S. centers (n = 1778, 1467 SLT, 311 BSLT) were used in the morbidity analysis.

RESULTS

Survival rates (%) computed using the Kaplan-Meier method at 30 days, 1 year, and 5 years for the patients aged < 50 years were 93.6, 80.2, and 43.6, respectively, for the SLT patients, and 94.9, 84.7, and 68.2, respectively, for the BSLT patients. For patients aged 50 to 60 years, survival rates (%) were 93.5, 79.4, and 39.8 for the SLT patients compared with 93.0, 79.7, and 60.5 for the BSLT patients. For those aged > 60 years, SLT survival (%) was 93.0, 72.9, and 36.4, compared with 77.8 and 66.0 for the BSLT group (a 5-year rate could not be completed in this group). The multivariate model showed a higher risk ratio for mortality in patients aged 40 to 57 years who received SLT vs BSLT. Recipient age and procedure type did not appear to affect the development of rejection, bronchiolitis obliterans, bronchial stricture, or lung infection.

CONCLUSIONS

Single lung transplant may offer acceptable early survival for patients with end-stage respiratory failure. However, long-term survival data favors BSLT in recipients until approximately age 60 years. These data suggest that a BSLT approach offers a significant survival advantage to recipients younger than 60 years of age.

The effect of nutritional status on morbidity in COPD patients undergoing bilateral lung reduction surgery

BACKGROUND

Although candidates for lung reduction surgery (LRS) include malnourished patients with severe chronic obstructive pulmonary disease (COPD), the impact of preoperative nutritional status on surgical outcome has not been clearly elucidated.

METHODS

We investigated the relationship between preoperative nutritional status and postoperative morbidity in 23 consecutive patients undergoing LRS. The percentage of ideal body weight (%IBW) and body mass index (BMI) were calculated, and fat-free mass (FFM) and fat mass (FM) were measured using a bioelectrical impedance analyzer. FFM and FM were expressed as height-normalized indices, FFM index [FFM (kg)/height (m)(2), or FFMI] and FM index [FM (kg)/height (m)(2), or FMI]. Serum levels of total protein and albumin were also determined.

RESULTS

8 patients had major complications. Preoperative %IBW and FFMI were significantly lower among patients with major complications, while no significant differences were observed in pulmonary function, FMI or serum protein. The complication rate was significantly higher among patients with low FFMI (FFMI < or = 16) but not with low %IBW or BMI.

CONCLUSION

These results suggest that FFM depletion is an excellent predictor of unacceptable postoperative complication following LRS.

Herniation of the lung after video-assisted thoracic surgery

We report a case of lung herniation occurring following video-assisted thoracic surgery. Although lung hernias are rare, the widespread application of video-assisted thoracic surgery to patients at risk for lung hernia will likely result in more reports in the future. Consequently, pulmonologists and thoracic surgeons must be aware of this condition, risk factors for development, and potential methods of prevention in order to minimize the occurrence of this complication.

Comparison of functional state between bilateral lung volume reduction surgery and pulmonary rehabilitation: a six-month followup study

STUDY OBJECTIVE

The effectiveness of bilateral lung volume reduction surgery (BLVRS) in the improvement of functional state in severe chronic obstructive pulmonary disease (COPD) has not been reported. This study examined the effects of BLVRS on subjective and objective measures of functional state (FS) and compared these effects with those gained from pulmonary rehabilitation (PR).

METHODS

Twenty-eight consecutive patients were studied. Of 13 BLVRS and 15 PR patients enrolled in the study, 12 and 13 patients, respectively, completed the 6-month protocol. Pulmonary function (FEV1, FVC, and FEF25-75) was measured by spirometry. Subjective FS was measured with the activity component of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) and objective FS was determined as the 6-min walk distance (6mwD). Additionally, the maximal dyspnea intensity measured with the Borg scale during the 6-min test was recorded. All outcomes were recorded prior to, and six months following treatment.

RESULTS

In patients undergoing BLVRS, FEV1 and FVC increased (17.3% and 16.8%) while in those treated with PR alone, FEV1 and FVC decreased (7.6% and 16.1%,p < 0.05). The subjective functional state (PFSDQ) was also significantly different between BLVRS and PR alone (PFSDQ = -49.4% vs. +4.7%, p < 0.05). Although the absolute distance walked over 6 min did not reach statistical significance, the BLVRS group increased the distance by 20% while the PR alone group had a decrease (-28%). Both groups demonstrated a reduction in dyspnea with exercise but the volume reduction patients showed a significantly greater reduction (PR = -1.0; BLVRS = -2.6, p < 0.05).

CONCLUSION

BLVRS results in greater improvement in pulmonary function, dyspnea with exercise, and subjective FS when compared to PR 6 months after surgery.

Dietary support to underweight patients with end-stage pulmonary disease assessed for lung transplantation

BACKGROUND

Undernutrition in hospitalized patients is often not recognized and nutritional support neglected. Chronic obstructive pulmonary disease is frequently characterized by weight loss. No data exist on the effects of nutritional supplementation in underweight lung transplantation candidates during hospitalization.

OBJECTIVE

To evaluate the effects on energy intake and body weight of an intensified nutritional support compared to the regular support during hospitalization.

METHODS

The participants were underweight (n = 42) and normal-weight (n = 29) patients with end-stage pulmonary disease assessed for lung transplantation. The underweight patients were randomized to receive either an energy-rich diet planned for 10 MJ/day and 45-50 energy percentage fat and offered supplements (group 1), or the normal hospital diet planned for 8.5-9 MJ/day and 30-35 energy percentage fat and regular support (group 2, control group). The normal-weight control patients (group 3) received the normal diet. Food intake was recorded for 3 days.

RESULTS

During a mean hospital stay of 12 days, the energy intake was significantly greater for the patients on intensified nutritional support (median 11.2 MJ) than for the underweight patients on the regular support (8.4 MJ; p < 0.02) and the normal-weight patients (7.0 MJ; p < 0.001). The increase in energy intake in group 1 resulted in a significant weight gain (median 1.2 kg) compared with group 2 (p < 0.01) and group 3 (p < 0.001).

CONCLUSIONS

In a group of underweight patients with lung disease assessed for lung transplantation, it was possible to increase energy intake by an intensified nutritional support which was associated with a significant weight gain, compared to the regular nutritional support during a short hospital stay.

Inspiratory lung impedance in COPD: effects of PEEP and immediate impact of lung volume reduction surgery

Frequency-dependent characteristics of lung resistance (RL) and elastance (EL) are sensitive to different patterns of airway obstruction. We used an enhanced ventilator waveform (EVW) to measure inspiratory RL and EL spectra in ventilated patients during thoracic surgery. The EVW delivers an inspiratory flow waveform with enhanced spectral excitation from 0.156 to 8.1 Hz. Estimates of the coefficients in a trigonometric approximation of the EVW flow and transpulmonary pressure inspirations yielded inspiratory RL and EL spectra. We applied the EVW in a group with mild obstruction undergoing various thoracoscopic procedures (n = 6), and another group with severe chronic obstructive pulmonary disease undergoing lung volume reduction surgery (n = 8). Measurements were made at positive end-expiratory pressure (PEEP) of 0, 3, and 6 cmH(2)O. Inspiratory RL was similar in both groups despite marked differences in spirometry. The chronic obstructive pulmonary disease patients demonstrated a pronounced frequency-dependent increase in inspiratory EL consistent with severe heterogeneous peripheral airway obstruction. PEEP appears to have beneficial effects by reducing peripheral airway resistance. Lung volume reduction surgery resulted in increased inspiratory RL and EL at all frequencies and PEEPs, possibly due to loss of diseased lung tissue, pulmonary edema, increased mechanical heterogeneity, and/or an improvement in airway tethering.

The flexible bronchoscopic approach to lung volume reduction

Surgical lung volume reduction is effective in patients with chronic obstructive pulmonary disease (COPD) because it improves the ratio between residual lung volume and total lung volume. The same effect may be achieved by inducing an iatrogenic atelectasis in one or more lung lobes using a flexible bronchoscopic approach. This article discusses the origin and the progress, up to date, of this new minimally invasive flexible bronchoscopic approach.

Severe pulmonary hypertension associated with COPD

Pulmonary hypertension can be associated with chronic obstructive pulmonary disease (COPD). Mild to moderate elevations in pulmonary artery pressures are commonly reported. Previous studies included patients initially diagnosed with COPD and subsequently evaluated for pulmonary hypertension. The occurrence of COPD in patients being evaluated for pulmonary hypertension has not been reported. We performed a retrospective chart review of approximately 600 patients evaluated in a large tertiary care pulmonary hypertension clinic. Subjects were included if they were older than 40 years, had no other secondary causes of pulmonary hypertension and had evidence of COPD by pulmonary function studies or thoracic computed tomography. Criteria was met by five subjects (3 males and 2 females, mean age = 65 years) all of whom were past smokers. The average mean pulmonary artery pressure (MPAP) was 59 +/- 7 mm Hg. The mean pulmonary vascular resistance (PVR) was 15.2 +/- 5 mmHg/liter/min. Only one patient had a fall in MPAP of more than 10% and a greater than 30% decline in PVR following infusion of adenosine to test vasodilator responsiveness. COPD is rare in a population referred primarily for evaluation of pulmonary hypertension. Although infrequent, severe pulmonary hypertension may be associated with COPD.

Surgery for chronic obstructive pulmonary disease: the place for lung volume reduction and transplantation

Lung volume reduction surgery and lung transplantation have been shown to improve lung function, exercise capacity, and quality of life in patients with advanced emphysema. Because the indications for both surgical procedures overlap, lung volume reduction surgery may be used as an alternative treatment or as a "bridge" to lung transplantation. In this article, we discuss patient selection, clinical outcome parameters, and the morbidity and mortality associated with each surgical procedure. We focus on the different preoperative predictors of good and poor outcomes after lung volume reduction surgery, the role of pulmonary rehabilitation, and the preferred surgical techniques for lung volume reduction surgery. An overview of the postoperative care of emphysema patients who undergo single-lung transplantation is also discussed.

Pre-transplant corticosteroid use and outcome in lung transplantation

BACKGROUND

The early experience of lung transplantation was plagued with airway anastomotic complications. The use of corticosteroids in the pre-transplant period has been implicated as a major contributing factor in bronchial dehiscence, and many patients have been denied transplantation on the basis of corticosteroid use. We conducted the current study to assess the risks associated with pre-transplant corticosteroid use.

METHODS

We analyzed records of 73 single- and bilateral-single lung transplant recipients who had chronic obstructive pulmonary disease or alpha(1)-antitrypsin deficiency as their underlying disease from 1986 to 1996. Twenty-six patients (steroid group) received daily corticosteroid therapy (prednisone, 1.5 to 40 mg/day) up to the time of transplantation, whereas 47 patients did not receive chronic corticosteroids and had no corticosteroid therapy within 3 months of transplantation (non-steroid group).

RESULTS

The demographic profiles of the 2 groups were comparable. We noted no statistical significances in length of hospital stay, duration of intensive care, and post-operative pulmonary function. The rates of cytomegalovirus infection, acute rejection, bronchiolitis obliterans syndrome, and survival were also similar. The non-steroid group seemed to have a higher rate of bronchial stenosis at 3 years (29% vs 6%, p = 0.03). Bronchial dehiscence did not occur in either study group.

CONCLUSIONS

Pre-transplant use of corticosteroids does not adversely affect outcome following lung transplantation.

Lung volume reduction surgery for chronic obstructive pulmonary disease: where do we stand?

Lung volume reduction surgery (LVRS) is a promising new treatment for selected patients with moderate to severe symptoms of emphysema. Medical management, including pulmonary rehabilitation, has been shown to reduce oxygen requirements during exercise and probably to reduce hospitalization for patients with severe emphysema, but it does not improve pulmonary function. By improving the elastic recoil of the lung, LVRS is the first treatment to demonstrate substantial improvement in pulmonary function and quality of life for selected patients with emphysema. The most important selection factor for LVRS is the presence of a heterogeneous pattern of emphysema. Because it is found in only 20% of patients with emphysema, only a small number of patients are candidates for the procedure. Published reports indicate that the optimal operative technique appears to be a bilateral staple operation during a single anesthetic. This procedure offers a 68% chance of oxygen independence, 85% chance of prednisone independence, and 60% to 70% improvement in pulmonary function for patients with an upper lobe distribution of emphysema. The long-term benefits of the procedure are currently unknown, so several randomized, prospective studies are now comparing LVRS with maximal medical management.

Hemodynamic unloading leads to regression of pulmonary vascular disease in rats

OBJECTIVE

Treatment options for patients with advanced pulmonary vascular disease caused by a congenital heart defect are still mainly limited to heart-lung transplantation or lung transplantation with repair of the cardiac lesion. Because we have previously shown that the structural changes associated with pulmonary hypertension can be reversed by stress unloading in an organ culture model, we now investigate whether hemodynamic unloading will lead to regression of pulmonary vascular disease in the intact animal.

METHODS

Right middle and lower lobectomy and monocrotaline injection were performed in Lewis rats (n = 22) to cause pulmonary vascular disease from a combined hemodynamic and toxic injury. Twenty-eight days later the left lungs were examined (n = 10) or exposed to normal pulmonary artery pressure for an additional 14 (n = 5) or 28 (n = 7) days by transplantation into healthy recipients. Pulmonary artery pressure, ventricular weight, and pulmonary artery morphology were evaluated in each group.

RESULTS

Pulmonary hypertension (50 vs 16 mm Hg; P <.001) and right ventricular hypertrophy (right ventricular/left ventricular weight 0.69 vs 0.32; P <.001) associated with pulmonary artery medial hypertrophy (28.2% vs 7.2% wall thickness; P <.001) and muscularization of small pulmonary arteries (92.3% vs 19.4%; P <.001) developed by day 28 (compared with untreated controls). However, transplantation into healthy recipients effectively unloaded the lungs (mean pulmonary artery pressure 17 and 24 mm Hg at 14 and 28 days after transplantation) and resulted in progressive normalization of medial hypertrophy (15.6% and 12.1% at 14 and 28 days) and muscularization (65.1% and 42.2% at 14 and 28 days) relative to nontransplanted controls (P <.005 in each case).

CONCLUSIONS

Hemodynamic unloading of lungs with pulmonary vascular disease results in progressive normalization of pulmonary artery structure. These results are the first to provide a rationale for attempting to induce regression of pulmonary vascular disease by pressure unloading of the pulmonary circulation. Methods to mechanically unload the pulmonary circulation should be critically evaluated as a strategy for staged surgical repair of congenital heart defects despite presumed irreversible pulmonary hypertension.

Psychosocial responses of adolescent cystic fibrosis patients to lung transplantation

What psychosocial issues do adolescent cystic fibrosis (CF) patients experience after undergoing lung transplantation (Tx)? The aim of this study was to determine, using an ethnographic study design, the common themes and emotional responses in post-lung transplant adolescent CF patients of the Cardiothoracic Transplant Clinic at the Childrens Hospital Los Angeles. Nineteen CF lung transplant recipients were studied (eight males, 11 females: mean age at time of transplant, 15.7 +/- 2.7 yr). The mean time interval from Tx to interview was 25.4 months (range 1-58 months). Sixteen patients had living donor lobar lung Tx while three patients received cadaveric lungs. A series of 25 questions was used to assess the psychosocial impact of Tx, and a semi-structured interview focused on the following five domains: lifestyle, family functioning, social functioning, body image, and psychological functioning. The major themes identified by patients included: a strong desire to set and attain meaningful long-range goals, the need to control as many aspects of their lives as possible while dealing with parental over-protectiveness, and the adjustment to a new lifestyle. Common emotional responses included manageable fear/anxiety of lung rejection and uncertainty of the future, impatience with disruptions of daily routines caused by post-transplant medical management and its effect on the attainment of set goals, and frustration with parental over-protectiveness. In general, patients reported a positive outlook on life, with greater emphasis on sought-after goals as well as inter-personal relationships. This study demonstrates that adolescent CF transplant recipients develop long-term goals and plans for independence. By identifying and anticipating the emotional needs of this population, health care providers can assist patients in improving the quality of their lives from a physiological, as well as a psychological, viewpoint.

Maximal expiratory flow patterns after single-lung transplantation in patients with and without chronic airways obstruction

BACKGROUND

A biphasic-plateau pattern in the maximal expiratory flow-volume (MEFV) curve has been described after single-lung transplantation (SLT) in patients with chronic airways obstruction (CAO). It has been theorized that this pattern is either related to stenosis at the anastomotic or subanastomotic site, or the sum of the airflow contribution from the native lung with airways obstruction and transplanted lung.

SUBJECTS AND METHODS

We analyzed data in 16 patients with CAO who had undergone transplantations (5 men, 11 women; mean age [+/- SD], 53.8 +/- 4.9 years), and 9 patients with pulmonary vascular disease (PVD) without airways obstruction who had undergone transplantations (2 men, 7 women; mean age, 35.4 +/- 11.4 years).

RESULTS

In the patients with PVD, there were no significant changes in static or dynamic lung volumes or in the MEFV curve after SLT. In the patients with CAO, indexes of airways obstruction improved significantly after SLT, and the typical biphasic-plateau pattern developed in the MEFV curve. In one patient with CAO who required pneumonectomy of the native lung after SLT, the biphasic pattern was absent.

CONCLUSIONS

These results support the view that this MEFV pattern is a result of airflow from the native and transplanted lungs in patients with CAO. In addition, the results show that in patients with no prior airways obstruction, SLT does not alter static or dynamic lung volumes or maximal expiratory flow rate.

Marked improvement of neuropsychological impairment in a patient with chronic obstructive pulmonary disease after lung volume reduction surgery

This paper reports a case of a 71-year-old pulmonary emphysema patient with neuropsychological impairments that were markedly improved 6 months after he underwent lung volume reduction surgery (LVRS). He also underwent pulmonary rehabilitation before and after surgery. He was suspected of having memory impairment and attention disorder when he was referred for rehabilitation. The neuropsychologic test showed a general cognitive impairment, attention disorder, and verbal memory impairment. Magnetic resonance imaging showed moderate atrophy of the left hippocampal area, cortex, and lacunae infarction in the periventricular area. Interestingly, scores of the neuropsychologic test, as well as severity of dyspnea and lung function, remarkably improved 6 months after LVRS. These results suggested that the neuropsychological impairments in pulmonary emphysema patients can be improved after lung reduction surgery.

Prevalence and consequences of nutritional depletion in lung transplant candidates

Nutritional status was studied in lung transplant (LT) candidates. The hypotheses were that nutritional depletion was highly prevalent and lean body mass depletion was a risk factor for a higher mortality both before and after LT. Of 78 consecutive patients listed for LT, 16 (21%) died while on the waiting list, eight (10%) were alive awaiting LT, and 54 (69%) received a graft. Mean age was 42.3+/-4.4 (mean+/-SD). Thirty-eight per cent had a diagnosis of bronchiectasis or cystic fibrosis (BRO/CF), 33% of emphysema, 20% of idiopathic pulmonary fibrosis (IPF) and 8% of primary pulmonary hypertension. Body mass index (BMI) was 20.4+/-4.3 kg.m2, weight was 87.9+/-16.6% of ideal body weight (IBW). Patients were classed into four nutritional groups according to IBW and creatinine height index (CHI): 1: weight <90% IBW and CHI <60% of predicted (28% of cases); II: weight <90% IBW and CHI > or =60% (27%); III: weight > or =90% IBW and CHI <60% (17%); IV: weight > or =90% IBW and CHI > or =60% (28%). Overall, 72% were depleted corresponding to groups 1, II and III. Lean body mass depletion occurred despite normal weight in 17% of the cases (group III). Subjects with BRO/CF were mostly in groups 1, II, III whereas IPF were concentrated in group II. Lean body mass depletion was associated with more severe hypoxaemia, reduced 6-minute walking distance and a higher mortality while awaiting. After LT, duration of mechanical ventilation, time spent in intensive care unit (ICU) was related to initial body composition. Survival after LT was lowest in group III. To conclude, nutritional depletion in lung transplant candidates is highly prevalent and should be more precisely assessed with a special reference to lean body mass since it has specific consequences both while awaiting and after lung transplant. Attempts should be made to increase lean body mass before lung transplant.

Lung transplantation for chronic obstructive pulmonary disease

Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.

Lung volume reduction surgery versus conservative treatment in severe emphysema

Lung volume reduction surgery (LVRS) has been proposed for patients with severe emphysema to improve dyspnoea and pulmonary function. It is unknown, however, whether prognosis and pulmonary function in these patients can be improved compared to conservative treatment. The effect of LVRS and conservative therapy were compared prospectively in 57 patients with emphysema, who fulfilled the standard criteria for LVRS. The patients were divided into two groups according to their own decision. Patients in group 1 (n=29, eight females, mean+/-SEM 58.8+/-1.7 yrs, forced expiratory volume in one second (FEV1) 27.6+/-1.3% of the predicted value) underwent LVRS. Patients in group 2 (n=28, five females, 58.5+/-1.8 yrs, FEV1 30.8+/-1.4% pred) preferred to postpone LVRS. There were no significant differences in lung function between the two groups at baseline; however, there was a tendency towards better functional status in the control group. The control group had a better modified Medical Research Council (MMRC) dyspnea score (3.1+/-0.15 versus 3.5+/-0.1, p<0.04). Model-based comparisons were used to estimate the differences between the two groups over 18 months. Significant improvements were observed in the LVRS group compared to the control group in FEV1, total lung capacity (TLC), Residual volume (RV), MMRC dyspnea score and 6-min walking distance on all follow up visits. The estimated difference in FEV1 was 33% (95% confidence interval 13-58%; p>0.0001), in TLC 12.9% (7.9-18.8%; p>0.0001), in RV 60.9% 32.6-89.2%; p>0.0001), in 6-min walking distance 230 m (138-322 m; p<0.002) and in MMRC dyspnoea score 1.17 (0.79-1.55; p<0.0001). In conclusion, lung volume reduction surgery is more effective than conservative treatment for the improvement of dyspnoea, lung function and exercise capacity in selected patients with severe emphysema.

Bilateral versus single lung transplantation for chronic obstructive pulmonary disease: intermediate-term results

BACKGROUND

There is controversy regarding the transplant procedure of choice in chronic obstructive pulmonary disease. We reviewed our intermediate-term outcomes with single lung transplantation (SLT) versus bilateral lung transplantation (BLT).

METHODS

We retrospectively reviewed 130 patients with chronic obstructive pulmonary disease: 84 underwent SLT, 46 BLT. The mean age was 51.1 +/- 1.2 years for those who underwent BLT and 56.2 +/- 0.7 years for those who underwent SLT (p < 0.0001). Male patients represented 65% of the BLT group and 46% of the SLT group (p = 0.04). Spirometry and 6-minute walk tests were obtained preoperatively and at 3- to 6-month intervals. Posttransplant survival and survival from time of onset of bronchiolitis obliterans syndrome were calculated by Kaplan-Meier method. The mean follow-up was 32.4 months.

RESULTS

The 90-day mortality rate was 13.0% For BLT and 15.5% for SLT (p = 0.71). Actuarial survival rates at 1, 3, and 5 years were 82.6%, 74.6%, and 61.9% for BLT and 72.2%, 63.4%, and 57.4% for SLT; the favorable survival trend with BLT did not achieve statistical significance. There were no differences in preoperative spirometry or 6-minute walk tests. The improvements in forced expiratory volume in one second, forced vital capacity (FVC), and 6 MWT were significantly greater following BLT. The incidence of bronchiolitis obliterans syndrome was 22.4% in SLT and 22.2% in BLT; survival following onset of bronchiolitis obliterans syndrome was similar.

CONCLUSIONS

For patients with chronic obstructive pulmonary disease, BLT is associated with superior lung function, exercise tolerance, and a trend toward enhanced survival. Younger candidates may be best suited for BLT. Given the limited donor lungs, SLT remains the preferred alternative for all other patients.

[Lung transplantation: indications, techniques and results]

Lung transplantation is proposed for young patients with a severe disease that can be expected to be fatal within less than two or three years. The main indications are chronic respiratory failure induced by chronic obstructive lung disease, cystic fibrosis or pulmonary fibrosis, and severe primary or secondary (Eisenmenger syndrome) pulmonary hypertension. The type of transplantation, determined after an exhaustive work-up ruling out all contraindications, is generally a single lung transplantation if there is no bronchial infection or two-lung transplantation or heart-lung transplantation in case of bronchiectasis or pulmonary artery hypertension. Survival at 1, 3 and 5 years is 72, 57 and 43% respectively. Transplantation improves exercise capacity, quality of life and lung function. It normalizes hematosis in case of chronic respiratory failure and pulmonary hemodynamics in case of pulmonary hypertension. The risk of complications, dominated by infections and rejections, requires careful clinical, functional and endoscopic follow-up. Bacterial infections are frequent during the first weeks. The frequency of opportunistic infections can be reduced by anti-infectious prophylaxis strategies. The rejection can occur as an acute episode, frequent during the first 100 days, or is sometimes asymptomatic. Chronic rejection or obliterating bronchiolitis is the main mid-term complication after lung transplantation and is responsible for the low long-term survival rate with recurrent secondary infections due to frequent bronchial colonization with Pseudomonas aeruginosa. Improved prognosis of lung transplantation requires the development of new immunosuppressive agents with lower risk of infection and chronic rejection observed with current treatments.

Flow limitation and dynamic hyperinflation during exercise in COPD patients after single lung transplantation

STUDY OBJECTIVE

Using the negative expiratory pressure (NEP) method, we have previously shown that patients receiving single lung transplantation (SLT) for COPD do not exhibit expiratory flow limitation and have little dyspnea at rest. In the present study, we assessed whether SLT patients exhibit flow limitation, overall hyperinflation, and dyspnea during exercise.

METHODS

Expiratory flow limitation assessed by the NEP method and inspiratory capacity maneuvers used to determine end-expiratory lung volume (EELV) and end-inspiratory lung volume (EILV) were performed at rest and during symptom-limited incremental cycle exercise in eight SLT patients.

RESULTS

At the time of the study, the mean (+/- SD) FEV(1), FVC, functional residual capacity, and total lung capacity (TLC) amounted to 55 +/- 14%, 67 +/- 12%, 137 +/- 16%, and 110 +/- 11% of predicted, respectively. At rest, all patients did not experience expiratory flow limitation and were without dyspnea. At peak exercise, the maximal mechanical power output and maximal oxygen consumption amounted to 72 +/- 20% and 65 +/- 8% of predicted, respectively, with a maximal dyspnea Borg score of 6 +/- 3. All but one patient exhibited flow limitation and dynamic hyperinflation; the EELV and EILV amounted to 74 +/- 5% and 95 +/- 9% TLC, respectively. The patient who did not exhibit flow limitation during exercise had the lowest dyspnea score.

CONCLUSION

Most SLT patients for COPD exhibit expiratory flow limitation and dynamic hyperinflation during exercise, whereas maximal dyspnea is variable.

Acute respiratory failure after lung volume reduction surgery

In this study, we characterized patients who developed respiratory failure postoperatively after lung volume reduction surgery (LVRS). We retrospectively reviewed the records of 72 patients who underwent LVRS from February 1995 to February 1998, examining perioperative variables and complications. Twenty-one patients (29%) developed postoperative respiratory failure, five due to hypoxemia, nine due to hypercapnia, and seven secondary to hemodynamic instability. The hospital mortality was 33% among patients who developed respiratory failure. No preoperative clinical or physiologic variable (including percent ideal body weight, serum albumin, prednisone use, lung function, maximal O(2) uptake on exercise testing, 6-min walk distance, and hemodynamic parameters) was predictive of postoperative respiratory failure. Patients who developed respiratory failure were older (63 +/- 7 versus 57 +/- 8 yr, p = 0.01), had longer anesthesia time (188 +/- 96 versus 127 +/- 56 min, p = 0.001), had a higher incidence of coronary artery disease (40% versus 10%, p = 0.001) and performance of concomitant surgical procedures during the LVRS operation (40% versus 2%, p < 0.001) compared with those without respiratory failure. All patients who underwent simultaneous surgery, which were mostly for cardiac disease, developed respiratory failure. Risk factor analysis confirmed that older patients and those undergoing cardiac surgery combined with LVRS are at increased risk for postoperative respiratory failure.

Correlation of changes in quality of life after lung volume reduction surgery with changes in lung function, exercise, and gas exchange

STUDY OBJECTIVES

To evaluate correlations between improvement in quality of life (QOL) in patients with severe COPD before and after they undergo lung volume reduction surgery (LVRS) with changes in pulmonary function tests, gas exchange, exercise performance, and alterations in medical management.

DESIGN

Case-series analysis.

SETTING

University hospital.

PATIENTS

Forty-two patients (mean [+/- SD] age, 56+/-8 years; 53% women) with severe airflow obstruction (FEV(1), 0.62+/-0.2 L), and moderate to severe hyperinflation (total lung capacity [TLC], 6.9+/-1.7 L).

INTERVENTION AND MEASUREMENTS

All patients underwent bilateral LVRS via median sternotomy. Measurements of lung function, symptom-limited cardiopulmonary exercise testing, the total distance the patient was able to walk in 6 min in a corridor, and sickness impact profile (SIP) scores were made before and 3 months after LVRS. SIP scores are inversely proportional to the level of function and QOL.

RESULTS

Compared to baseline, FEV(1) increased (0.87+/-0.3 vs. 0.62+/-0.2 L, respectively; p<0.01) while residual volume significantly decreased (3.2+/-1.8 vs. 6.3+/-1.2 L, respectively; p<0.004) at 3 months post-LVRS. On cardiopulmonary exercise testing, values increased from baseline to post-LVRS for total exercise time (9.0+/-2.2 vs. 6.0+/-1.5 min, respectively; p = 0.045), maximum oxygen uptake (VO(2)) (16+/-3 vs. 11+/-2 mL/kg/min, respectively; p = 0.01), and maximum minute ventilation (VE) (33+/-9 vs. 28+/-5 L/min, respectively; p = 0.03). The percentage change in the oxygen cost of breathing (VO2/VE ratio) from low to high workloads during exercise was significantly lower after LVRS (p = 0.002). There was no significant change in oxygenation after LVRS (PaO(2)/fraction of inspired oxygen, 331+/-27 vs. 337+/-39, respectively; p = 0.76), but PaCO(2) tended to be lower (41+/-9 vs. 48+/-6 mm Hg, respectively; p = 0.07). Overall SIP scores were significantly lower after LVRS than before (8+/-4 vs. 15+/-2, respectively; p = 0.002). Changes in SIP scores correlated with the change in VO2/VE ratio from low to high workloads, with patients having the smallest changes in VO2/VE ratio having the smallest changes in SIP scores after LVRS (r = 0.6; p = 0.01). Improved or lower SIP scores also tended to correlate with a reduction in residual volume/TLC ratio (r = 0.45; p = 0.09), and there was a linear correlation with a statistically significant Pearson r value with decreased steroid requirements (r = 0.7; p = 0.001). Moreover, changes in psychological SIP subscore tended to correlate with diminished oxygen requirements post-LVRS (r = 0.45; p = 0.09). However, there was no significant correlation between changes in SIP scores and routine measurements of lung function, exercise performance, or gas exchange.

CONCLUSION

There is an association between an improvement in QOL and reduced hyperinflation after LVRS. Reduced hyperinflation may lead to more efficient work of breathing during exercise and, therefore, to an increased ability to perform daily activities. Changes in QOL scores correlate best with behaviorally based variables that directly affect the patient's well-being, such as systemic steroid administration.

Quantitation of regional ventilation during the washout phase of lung scintigraphy: measurement in patients with severe COPD before and after bilateral lung volume reduction surgery

STUDY OBJECTIVES

We sought to investigate the effect of lung volume reduction surgery (LVRS) on regional lung ventilation.

DESIGN

Retrospective analysis of routinely acquired data before and after LVRS.

SETTING

Large, urban, university medical center.

PATIENTS

Twenty-nine patients with severe emphysema.

INTERVENTION

Bilateral LVRS.

MEASUREMENTS AND RESULTS

(133)Xe washout curves during lung scintigraphy exhibit a biphasic pattern (the first component of the washout curve [m(r)] corresponds to an initial rapid phase in washout that reflects larger airways emptying, and the second component [m(s)] reflects a slower phase of washout that is attributed to gas elimination via smaller airways). We analyzed six standardized regions of the lung (upper, mid, and lower zones of the right and left lung), and calculated m(r) and m(s) for each lung region. The mean (+/- SE) baseline FEV(1) was 0.69+/-0.04 L, total lung capacity (TLC) was 139 +/-4% predicted, and the residual volume (RV)/TLC ratio was 65+/-2%. The mean improvement in FEV(1) 3 months post-LVRS was 38%. Post-LVRS, m(r) and m(s) increased in 79 and 74 lung regions, respectively, and there was no relationship with respect to lung regions that had or had not been operated on. The increase in m(s), however, significantly correlated with the increase in FEV(1) (r = 0.66; p<0.0001) and the decrease in RV/TLC (r = -0.67; p<0.0001). An increase in m(s) also correlated with a decrease in PaCO(2) (r = -0.39; p = 0.03), but m(r) showed no relationship with any parameter.

CONCLUSIONS

Small airways ventilation in lung regions that had and had not been operated on is associated with a greater improvement in lung mechanics following LVRS.

Health-related quality of life in lung transplant candidates and recipients

BACKGROUND

Studies on the health-related quality of life in lung transplantation have used general questionnaires, although lung-specific instruments might be more sensitive to small differences.

OBJECTIVES

To compare the health-related quality of life of lung transplant recipients with lung transplant candidates, using lung-specific and general instruments, and to assess the reliability and validity of these questionnaires.

METHODS

The study is a cross-sectional postal survey of 31 lung transplant recipients and 15 candidates, using the following outcome measures: St. George's Respiratory Questionnaire (SGRQ), a lung-specific health status instrument; the Short Form 36 (SF-36), a general measure, and the Hospital Anxiety and Depression scale (HAD).

RESULTS

The SGRQ showed a significantly better score (p < 0.05) for transplant recipients in the impacts and activity dimensions and the total score than for candidates. SF-36 scores showed a similar improvement in all subscales of the SF-36 except bodily pain. Cronbach's alpha for all dimensions of the SGRQ, SF-36, and HAD were 0.77-0.95.

CONCLUSIONS

Patients surviving lung transplantations can expect a considerable improvement in most dimensions of health-related quality of life. This finding was consistent using both lung-specific and general measures. The reliability of the questionnaires was acceptable. The associations between scales support the validity of the questionnaires in this setting.

Influence of clinical history on airways bacterial colonization in subjects with chronic tracheostomy

Patients with chronic tracheostomy are subject to significant bacterial colonization of the airways, a risk factor for respiratory infections. The aim of our study was to verify whether bacterial colonization and humoral immune response in the airways can be influenced by the disease which led to chronic respiratory failure and tracheostomy. Thirty-nine clinically stable outpatients with chronic tracheostomy were considered: 24 were affected by chronic obstructive pulmonary disease (COPD) (mean age 66 years, range 54-78, M/F 19/3; months since tracheostomy 23, range 3-62), 15 by restrictive lung disease (RLD) (12 thoracic wall deformities, three neuromuscular disease; age 57 years, range 41-72; M/F 3/12, months since tracheostomy 22, range 2-68). Recent antibiotic or corticosteroid treatments (< 1 month) were among exclusion criteria. Bacterial counts were assessed in tracheobronchial secretions with the method of serial dilutions. Identification of bacterial strains was performed by routine methods. Albumin, IgG, A, and M were measured in airways secretions with an immunoturbidimetric method. No significant differences were found between the two groups as regards either the quantitative bacterial cultures (RLD 81.4, 2.6-4200 x 10(4); COPD 75.9, 1.0-1530 x 10(4) colony forming units (cfu)/ml, geometric mean, range) or the prevalence of the main bacterial strains, (Pseudomonas species: 38 and 37%, Serratia marcescens: 31 and 23%, Staphylococcus aureus: 14 and 6%, Proteus species: 3 and 8%, for RLD and COPD respectively) as a percentage of total strains isolated (RLD = 26, COPD = 48). Immunoglobulin levels did not show significant differences, apart from being higher in underweight subjects. We conclude that in our series of stable outpatients with chronic tracheostomy, bacteria-host interaction in the airways was not influenced by the clinical history.