Differences in bronchodilating potency of salbutamol in Turbuhaler as compared with a pressurized metered-dose inhaler formulation in patients with reversible airway obstruction

Two studies are presented, with the aim of establishing the dose potency ratio for salbutamol given via Turbuhaler and via a pressurized metered-dose inhaler (pMDI). Both studies were of a double-blind, randomized design. Outpatients with mild-to-moderate chronic reversible airway obstruction were given single doses of salbutamol administered via Turbuhaler and via pMDI. Efficacy and safety variables were measured before and during 6 h after each dose. The first study was a four-way crossover study including 12 patients. The salbutamol doses given were: 50, 100 and 2x100 microg via Turbuhaler and 2x100 microg via pMDI (Ventolin). The study showed that 2x100 microg of salbutamol inhaled via Turbuhaler is more potent than 2x100 microg salbutamol inhaled via a pMDI, and that 100 microg salbutamol via Turbuhaler is at least as potent as 2x100 microg salbutamol inhaled via a pMDI. The second study including 50 patients was a placebo-controlled five-way crossover, study. Two doses of salbutamol via Turbuhaler, 50 and 2x100 microg, and via pMDI, 100 and 2x200 microg, were given. There was a dose-dependent response in forced expiratory volume in one second (FEV1) for both inhalers. Adjusted for differences in baseline FEV1 values, the estimated relative dose potency for Turbuhaler versus pMDI was 1.98:1 (95% confidence interval 12-3.2). These studies showed that the same bronchodilating effect can be achieved when half the dose of salbutamol given via a conventional pressurized metered-dose inhaler is given via Turbuhaler.

High frequency of endocrine autoimmunity in patients with sarcoidosis

Autoimmune diseases and sarcoidosis may be related and, especially, the association between sarcoidosis and autoimmune thyroid disease has long been recognized. The frequency and type of endocrine autoimmunity was examined in a series of Swedish patients with sarcoidosis. Of all patients (N = 89) with documented sarcoidosis attending the Department of Pulmonary Medicine between January 1980 and December 1991, 78 patients (44 males and 34 females; median age at the time of the study 48 years. range 22-81 years) were examined at the Department of Endocrinology, Malmö University Hospital, in the present study. Fifteen patients (19.2%) had clinical or serological evidence of endocrine autoimmunity. Two patients had Addison's disease, both with polyglandular autoimmune (PGA) syndrome type II: evidence of thyroid autoimmunity was found in 13 patients, eight with clinical autoimmune thyroid disease (ATD) (two with Graves' disease and six with autoimmune thyroiditis), of whom two had PGA syndrome type III, and five with isolated positive thyroid serology; two patients had insulin-dependent diabetes mellitus and one had premature ovarian failure. The frequencies of Addison's disease, clinical ATD and PGA syndrome type II were significantly higher compared with the frequencies found in the general population. In conclusion, a high frequency of endocrine autoimmunity in patients with sarcoidosis, occurring in about 20% of the cases, was demonstrated. Thyroid autoimmunity and polyglandular autoimmune syndromes occurred most frequently. Complex immunological and genetic mechanisms might explain the association of sarcoidosis and endocrine autoimmune diseases.

Kinetic retrieval of eosinophil cationic protein, hyaluronan, secretory IgA, albumin, and urea during BAL in healthy subjects

Determination of absolute concentrations of various soluble components of the epithelial lining fluid (ELF) may be valuable to estimate inflammatory activities within the underlying lung tissue. Internal standards may then be used as markers of dilution of bronchoalveolar lavage (BAL). The aim of this study was to determine whether different dwell times would affect the relationship between the concentrations of any of the three potential internal standards (secretory IgA [SIgA], albumin, and urea), and the concentrations of two potential markers of inflammation (eosinophil cationic protein [ECP] and hyaluronan [HA]) in BAL. A series of aliquots of BAL fluid were aspirated every 60 s up to 8 min after a bolus instillation of saline solution in 20 healthy subjects (10 smokers). The BAL concentrations of albumin and urea increased with time, consistent with continuous diffusion from the body water pool, absorption of the BAL fluid, or both. The rate constant of diffusion was 1,000 times higher for urea than for albumin (3.38 x 10(-1) and 3.64 x 10(-4), respectively), reflecting the difference in molecular weights, and in agreement with the notion that albumin and urea appeared in BAL fluid by a rate-limited procedure related to osmotic transfer. Biexponential increases of SIgA were recorded, suggesting a two-compartmental origin of this compound, normally located to mucosal membranes and presumed to be dissolved in ELF. Time-dependent increases in BAL fluid of HA also were recorded, but on the other hand, the ECP concentrations tended to level off after an initial increase, suggesting that the bulk of ECP appeared in BAL by a nonosmotic mechanism. We conclude that the kinetics of these three internal standards in BAL fluid differs greatly from each other and from the kinetics of the two selected markers of inflammation. Consequently, internal standards for determination of absolute concentrations of markers of inflammation in ELF should be carefully selected because of the requirement of matched kinetics of the markers.

The occurrence of polyglandular autoimmune syndrome type III associated with coeliac disease in patients with sarcoidosis

OBJECTIVES

To study whether an association between polyglandular autoimmune (PGA) syndrome type III [including autoimmune thyroid disease (ATD) and insulin-dependent diabetes mellitus (IDDM)], coeliac disease and sarcoidosis, exists.

DESIGN

In patients with documented sarcoidosis, the presence of the disease constellation of ATD, IDDM and coeliac disease was examined.

SETTING

The patients were recruited at the Department of Pulmonary Medicine, and the study was conducted at the Department of Endocrinology, Lund University Clinics, General Hospital, Malmö, Sweden.

SUBJECTS

Of all patients (n = 89) with documented sarcoidosis attending the Department of Pulmonary Medicine between January 1980 and December 1991, 78 patients (44 males, 34 females: median age at the time of the study 48 years, range 22-81 years: median observation time since the diagnosis of sarcoidosis 120 months, range 1-468 months) were examined in the present study.

RESULTS

Amongst the 78 patients with documented sarcoidosis, one female patient was found with PGA syndrome type III, coeliac disease and sarcoidosis.

CONCLUSIONS

This present patient further indicates the existence of an association between polyglandular autoimmune (PGA) syndrome type III, coeliac disease and sarcoidosis. To determine whether this disease constellation might constitute a new syndrome, further studies on larger groups of patients with sarcoidosis are demanded.

Chest physiotherapy in chronic obstructive pulmonary disease: forced expiratory technique combined with either postural drainage or positive expiratory pressure breathing

The aim of this study was to measure the short-term effects on mucus clearance after forced expiratory technique (FET) combined with either postural drainage (PD) or positive expiratory pressure breathing (PEP) on two different days. We also wanted to assess the patient's preference to the two methods. We measured mucociliary clearance at rest and during physiotherapy in 14 patients with chronic obstructive pulmonary disease. The subjects inhaled an aerosol containing 99mTc-labelled albumin colloid. Five sets of scintigraphic images were obtained with 22-min intervals. Lung retention of radioactivity was quantified using a gamma camera and the clearance of particles from the lungs calculated for each 22-min period. The first image was obtained directly after inhalation, the second after a period of 22 min rest, the third after physiotherapy and the fourth and fifth images after further periods of rest. Clearance from the whole lung and from central and peripheral regions were much greater after physiotherapy than at rest. Clearance during PD+FET was significantly higher than during PEP+FET in the total lung field (P < 0.05) and in the peripheral region (P < 0.004). The patients found the two methods equally efficient but most of the patients preferred PEP as a treatment.

Granulocytes and their secretory products, myeloperoxidase and eosinophil cationic protein, in bronchoalveolar lavage fluids from two lung lobes in normal subjects

The interlobar variability of lavage neutrophils and eosinophils was studied in twelve healthy subjects. In addition, the interlobar variation of the neutrophil cell marker myeloperoxidase (MPO) and the eosinophil cell marker eosinophil cationic protein (ECP) was assessed. Bronchial washes (BW), as defined by the first aspirated lavage aliquot, and bronchoalveolar lavage (BAL) fluids were compared. One subsegment of the right middle lobe and one subsegment of the right lower lobe were lavaged in the same session. Interlobar consistency of neutrophil and eosinophil cell recoveries was observed but, in contrast, the levels of MPO or ECP did not correlate in lavage fluids aspirated from the two lobes. These results suggest that BAL cell content from a single lobe of the lung in healthy subjects does reflect the cell populations throughout the airways, while the levels of soluble proteins may differ between the lobes. Such a variation questions the correlation between cells and their secretory products or the correlation between levels of solutes in lavage fluid and in the underlying tissue. Further methodological studies appear warranted to elucidate whether cell and solute recoveries accurately reflect the underlying pathology.

Myeloperoxidase in human lung lavage. II. Internalization of myeloperoxidase by alveolar macrophages

Bronchial wash and bronchoalveolar lavage were performed in 12 healthy subjects (five smokers), in order to elucidate whether or not material of neutrophil origin may be phagocytized by lung macrophages in vivo. Cells from different levels in the bronchial tree were obtained by sequential injection and subsequent aspiration of either four 50-ml or five 10-ml aliquots. Each aliquot was used for the determination of total and differential cell counts. The proportion of myeloperoxidase-positive alveolar macrophages was determined by specific immune histochemical staining. The percentage of myeloperoxidase-positive macrophages was highest (median 94.8%, range 37-98.5%) in the 10-ml aliquots and lowest in the last three 50-ml aliquots (median values 1-2.5%) (P less than 0.001). A significant correlation was obtained between the fraction of myeloperoxidase-positive macrophages and the percentage count of bronchoalveolar lavage neutrophils (r = 0.466, P less than 0.05). Furthermore, the cellular myeloperoxidase showed a significant inverse correlation (r = -0.46, P less than 0.05) to the viability of the bronchoalveolar lavage cells. Our findings are compatible with previous demonstrations in animals of neutrophil phagocytosis by lung macrophages and show that this phenomenon in particular occurs in the more proximal airways. The internalization of neutrophils or neutrophil components by airway macrophages may be an important scavenger mechanism for protection of the lung from the deleterious effects of activated neutrophils.

Theophylline in maintenance treatment of chronic asthma: concentration-dependent additional effect to beta 2-agonist therapy

The effect of long-term treatment with theophylline was studied in 20 chronic asthmatic patients receiving oral and inhaled beta 2-agonists. In a double-blind, randomized cross-over fashion during three consecutive 6-week periods, the patients received theophylline in individually adjusted dosages or placebo to obtain plasma concentrations of 25-45 mumol/l, 50-85 mumol/l and 0, respectively. PEF, beta 2-aerosol consumption, symptom scores and side-effects were recorded daily. The addition of theophylline caused a significant further bronchodilating effect. There was, however, a large interindividual variation in response to additional theophylline and only half of the subjects were responders. Those responding had increased therapeutic efficacy from a steady-state concentration in the range of 50-85 mumol/l compared to the lower concentration. The responders had, on average, more pronounced air-flow obstruction. The incidence of adverse reactions increased with increasing concentrations of theophylline.

Ventilation-perfusion relationships in interstitial lung disease

Ten patients with interstitial lung disease were studied with regard to pulmonary gas exchange and diffusion limit at rest and during exercise. The total lung capacity was reduced to 64% and the transfer factor of the lung to 36% of reference. Pulmonary vascular resistance was increased by 50% above the upper normal limit. The ventilation-perfusion relationship (VA/Q), assessed by a multiple inert gas elimination technique, showed 2% shunt and 5% of lung blood flow perfusing regions with a low VA/Q (VA/Q less than 0.1) at rest. PaO2 derived from the VA/Q distribution was 9.3 kPa and correlated significantly (p less than 0.01) with measured PaO2 (9.9 kPa). During light exercise (30 W), the sum of the shunt and perfusion of low VA/Q regions was unaltered (7%), and PaO2 derived from the VA/Q distribution was the same as at rest (9.0 kPa). Measured PaO2 fell, however, to 7.1 kPa and the alveolar-oxygen tension difference (P(A-a)O2) was doubled to 7.0 kPa. It is concluded that a limitation on diffusion across the alveolar-capillary membrane developed during exercise, contributing approximately 30% to P(A-a)O2.

Separate and combined use of terbutaline and theophylline in asthmatics. Effects related to plasma levels

The bronchodilating properties and side effects of theophylline and a beta 2-adrenoceptor stimulating drug (terbutaline) alone and in combination were studied in 10 adult asthmatic patients. Initially, each individual's pharmacokinetic parameters for theophylline were determined. On 3 separate days theophylline was infused to defined steady-state concentrations (0, 7.5, and 15 microgram/ml, respectively) followed by the administration, at 1-h intervals, of incremental i.v. doses of terbutaline. It was shown that: 1. Theophylline caused a concentration-dependent increase in FEV1. Theophylline itself had no significant effect on objectively recorded skeletal muscle tremor or heart rate but enhanced the terbutaline-induced increase in tremor and heart rate. At the highest concentration (15 microgram/ml) two of the patients experienced nausea. 2. Terbutaline caused a concentration-dependent increase in FEV1, heart rate, and tremor. The plasma levels of terbutaline at the given doses did not differ significantly between individuals or within individuals at the different theophylline levels. 3. The combination of theophylline and terbutaline resulted in a mere additive effect on the bronchodilatation. At comparable bronchodilatation the combination of theophylline and terbutaline caused a lesser degree of side effects than each of the drugs alone.

Hexoprenaline and terbutaline administered by inhalation. A comparison between two beta2-adrenoreceptor agonists with respect to effect on bronchial obstruction, heart rate, blood pressure and muscle tremor

In a controlled double-blind cross-over study in 15 patients with reversible bronchial obstruction hexoprenaline (Ipradol, 0.20 mg/puff) and terbutaline (Bricanyl, 0.25 mg/puff) when administered as metered aerosol in a dosage of one puff followed by two puffs 30 min later produced the same maximum improvement of ventilatory function. However, after inhalation of terbutaline a more sustained broncholytic effect was obtained than after hexoprenaline. Similar results were obtained in six patients after doubling the dose of each agent. The influence on pulse rate and blood pressure was negligible with either agent. The amplitude of finger tremor was measured after 2 + 4 puffs. No significant changes in mean values occurred after either of the two agents although after hexoprenaline an increase in amplitude of more than 100% was recorded in two out of six patients 30 min after the second dose.