Clinical management of asthma in the 1990s. Current therapy and new directions.

Asthma is a serious global health problem affecting nearly 100 million people worldwide. Its rising prevalence and associated morbidity and mortality are of increasing concern. Traditionally, symptomatic control of bronchoconstriction with beta 2 agonists and theophylline has been the mainstay of therapy. However, during recent years, inflammation has been recognised as the predominant cause of reversible airway obstruction and airway hyperreactivity. As a result, the emphasis in treatment has shifted to the early use of inhaled corticosteroids to control airway inflammation. beta 2 agonists are best used on an as-needed basis for the relief of acute bronchoconstriction and for the prevention of exercise-induced asthma. Sustained release theophylline or an inhaled long-acting beta 2 agonist may effectively control nocturnal symptoms. Preliminary studies involving agents active in the 5-lipoxygenase pathway as preventive therapy are encouraging. Further studies are needed to define their role in the management of asthma.

Giant esophageal varices. An unusual cause of a posterior mediastinal mass.

Esophageal pathology rarely presents as posterior mediastinal abnormalities on chest roentgenograms, with the most common being hiatal hernia. We describe a patient with giant esophageal varices manifesting as a retrocardiac, posterior mediastinal mass.

The safety of outpatient transbronchial biopsy.

Fiberoptic bronchoscopy (FOB) is an accepted outpatient procedure, but transbronchial biopsy (TBB) is generally reserved for hospitalized patients. Over a three-year period, we performed fluoroscopically guided TBB in 148 of 688 outpatients undergoing FOB. Following the procedure, fluoroscopy was used to screen for possible pneumothorax in those patients who had had TBB. All patients were observed for one hour and then discharged if stable. Three patients (2.02 percent) were admitted and observed for acute hemoptysis following TBB. Bleeding ceased spontaneously in each. The remaining 145 patients were discharged after one hour of observation. One patient (0.68 percent) required Heimlich tube treatment for a delayed pneumothorax. Our experience indicates a low incidence of delayed complications in patients who are asymptomatic for one hour following TBB. We conclude that patients do not require hospitalization solely for TBB.

Survival experience following Nd:YAG laser photoresection for primary bronchogenic carcinoma.

We followed the course of 47 consecutive patients with inoperable primary bronchogenic carcinoma who underwent palliative neodymium-yttrium-aluminum-garnet laser photoresection (YPR) between September 1983 and September 1986. Of these 47, 35 (74.5 percent) underwent both radiation therapy (XRT) and YPR. The survival of these 35 patients (median survival, 304 days) was compared with that of 58 who underwent only palliative palliative XRT (median survival, 253 days) from 1981 to 1983, when YPR was not yet available at our institution. There was no significant difference in overall survival (p = 0.17). A significant increase in survival (p = 0.04) was seen in 15 patients who underwent emergency palliative YPR as the initial therapeutic intervention compared with 11 patients who received emergency palliative XRT but would have received YPR had it been available at that time. A trend toward increased survival was also shown in patients who underwent endobronchial radiation therapy in addition to YPR and XRT.

Nocturnal hypoxemia is common in primary pulmonary hypertension.

STUDY OBJECTIVE: Unsuspected sleep-related respiratory events are common in patients with severe pulmonary disease. Sleep in patients with primary pulmonary hypertension (PPH) has not been studied (to our knowledge). The purpose of this study was to measure the prevalence of respiratory disturbances and nocturnal hypoxemia during the sleep of patients with PPH. SETTING: Tertiary-care referral hospital. DESIGN: Retrospective review. PATIENTS: Thirteen patients with PPH. MEASUREMENTS: All patients underwent a single-night comprehensive polysomnogram study. Patients who spent > 10% of the total sleep time with oxygen saturation by pulse oximetry (SpO(2)) at < 90% or who needed oxygen to maintain their SpO(2) level at > 90% were classified as nocturnal desaturators. Analysis was performed to determine which clinical variables (ie, demographics, body mass index, spirometry, diffusion capacity, right heart catheterization pressures, 6-min walk test, arterial blood gas levels, resting and walking SpO(2) levels, and polysomnogram variables) would predict nocturnal desaturation. Statistical significance was considered when p values were < 0.05. RESULTS: Of the 13 patients in the study, 10 (77%) were nocturnal desaturators. All patients had normal apnea indexes, but two had mild elevations of the hypopnea index (< 15 episodes per hour). Nocturnal desaturations occurred independently of apneas or hypopneas. Six patients who did not have O(2) titration during sleep spent > 25% of sleep time with SpO(2) < 90%. The mean (+/- SD) variables that were significantly different between desaturators (10 patients) and nondesaturators (3 patients) were FEV(1) (70.1 +/- 9.1% predicted vs 98.1 +/- 15.1% predicted, respectively; p = 0.002), resting PaO(2) (61.8 +/- 16.1 vs 90.3 +/- 2.3 mm Hg, respectively; p = 0.001), alveolar-arterial oxygen pressure difference (P[A-a]O(2)) (40.5 +/- 20.5 vs 12.2 +/- 7.2 mm Hg, respectively; p = 0.048), resting SpO(2) (91.6 +/- 5.4% vs 98.7 +/- 2.3%, respectively; p = 0.038), and walking SpO(2) (83.8 +/- 9.3% vs 95.3 +/- 1.2%, respectively; p = 0.002). The mean hemoglobin level was higher in the group of nocturnal desaturators than in the group of nondesaturators (10.43 +/- 0.31 vs 13.95 +/- 0.98 g/dL, respectively; p < 0.0001). CONCLUSION: Seventy-seven percent of patients with PPH have significant nocturnal hypoxemia that is unrelated to apneas and hypopneas. Nocturnal desaturation occurs more frequently in patients with higher P(A-a)O(2) values and lower FEV(1) values, resting arterial PaO(2) and SpO(2) values, and walking SpO(2) values.

Pulmonary lymphoid neoplasms. Role of immunohistology in the study of cellular immunotypes and in differential diagnosis.

Seven cases of lymphoid neoplasms presenting in the lung were evaluated by immunohistology for T and B cell antigens and immunoglobulin light chains in frozen tissue sections. Although follow-up was short or inconclusive in some patients with lymphoma and pseudolymphoma, it was concluded that evaluation of T and B cell antigens and immunoglobulin light chains in frozen tissue is helpful in classifying lymphocytic neoplasms, especially in cases without definite cytologic evidence of malignancy. As demonstrated in two additional cases, lymphocyte/leukocyte markers in paraffin-embedded tissue are important in the differential diagnosis of lesions with cytologic features of malignancy.

Dynamic pharyngoscopy in predicting outcome of uvulopalatopharyngoplasty for moderate and severe obstructive sleep apnea.

STUDY OBJECTIVE: We sought to determine whether preoperative fiberoptic pharyngoscopy (FOP) with Müller's maneuver (dynamic FOP) could be used to establish a subgroup of obstructive sleep apnea (OSA) patients with better outcome after uvulopalatopharyngoplasty (UPPP). DESIGN: Retrospective review of an observational cohort. SETTING: Tertiary care referral center. PATIENTS: Twenty-nine patients who underwent UPPP and nasopharyngeal surgery by one surgeon. INTERVENTION: The patients were divided into two groups based on the findings of preoperative dynamic FOP: group 1 (11 patients) had collapse of the velopharynx and the base of the tongue-epiglottis-hypopharynx (TEH) complex and group 2 (18 patients) had velopharyngeal collapse only. MEASUREMENTS AND RESULTS: Surgical success was defined using a conventional definition (> 50% reduction in the apnea-plus-hypopnea index [OAHI]), and a criterion for cure (> 90% reduction in OAHI and postoperative OAHI < 15). Both groups had a significant improvement in their OAHI. The success rate was significantly higher in patients with velopharyngeal collapse only compared with patients with additional collapse of the TEH complex (78 vs 36% with the conventional definition, and 50 vs 9% using the definition for cure, respectively). Predictive value of dynamic FOP in predicting cure failure when collapse of the TEH complex was present was 91%. CONCLUSIONS: Dynamic FOP may help establish a subgroup of OSA patients with greater likelihood of successful UPPP. The high negative predictive value of dynamic FOP when a criterion for cure is used suggests that this maneuver could best be used to exclude patients with TEH complex collapse from UPPP.

Pulmonary manifestations of vinyl and polyvinyl chloride (interstitial lung disease). Newer aspects.

Newer varieties of occupational lung diseases primarily due to the vast increase in industrial technology have been reported recently. Preeminent among such newer agents are vinyl chloride (VC) and polyvinyl chloride. Very few cases have been reported, in Europe only, with descriptive histopathologic changes. To our knowledge, no pathologic studies of VC exposure have been described in the American literature. The biopsy abnormalities in our patients disclosed desquamation of alveolar macrophages into the alveolar lumina and minor interstitial and alveolar inflammatory changes. Pulmonary function abnormalities included restrictive insufficiency. Preventive therapy consists of the avoidance of further exposures, frequent industrial hygiene monitoring, and total avoidance of tobacco smoke, as well as associated atmospheric pollutants. Thus far, none of these patients has exhibited evidence of pulmonary neoplasms. All three patients survived their occupational injuries, and two are still disabled to varying degrees. Urine and blood levels of phthalic acid derivatives were elevated in two patients, the exact significance of which is not fully known. It probably represents a toxicologic response, but must be further pursued before conclusions can be reached.

An arrhythmia detector and heart rate estimator for overnight polysomnography studies.

We present an algorithm for automatic on-line analysis of the electrocardiography (ECG) channel acquired during overnight polysomnography (PSG) studies. The system is independent of ECG morphology, requires no manual initialization, and operates automatically throughout the night. It highlights likely occurrences of arrhythmias and intervals of bad signal quality while outputting a continual estimate of heart rate. Algorithm performance is validated against standard ECG databases and PSG data. Results demonstrate a minimal false negative rate and a low false positive rate for arrhythmia detection, and robustness over a wide range of noise contamination.

Pulmonary artery agenesis presenting as massive hemoptysis--a case report.

Massive hemoptysis is the expectoration of approximately 600 ml of blood in twenty-four hours. Major causes of massive hemoptysis are tuberculosis, bronchiectasis, pulmonary neoplasm, fungus ball, bronchial adenomas, lung abscess, intrabronchial rupture of an aortic aneurysm, cystic fibrosis, pulmonary infarction, and pulmonary trauma. Other, less common causes include Goodpasture's syndrome, broncholiths, pulmonary varix, A-V malformation, and bleeding disorders. Agenesis of the pulmonary artery usually occurs in association with congenital cardiac anomalies, and isolated unilateral absence of the pulmonary artery is uncommon. About 10% of the patients with pulmonary artery agenesis develop inconsequential hemoptysis, but massive hemoptysis is a very rare complication of this anomaly. The following is a case report of a twenty-nine-year-old man with agenesis of the left pulmonary artery, who presented with massive hemoptysis requiring embolization and, eventually, pneumonectomy.

Quantitation of abnormal 67Ga uptake in pulmonary interstitial vascular disease--a new test to detect diffuse lung disease.

Gallium 67 has been used as a modality to diagnose and follow the clinical course of diseases such as tumors, infections, inflammatory disorders, and interstitial lung disease. It has been appreciated, however, that mild to moderate changes in scan activity, when these disorders are followed over time, are less than optimal. SPECT (single-photon emission computed tomography) scanning is a new technique designed to obviate this problem. SPECT scanning utilizes computer acquisition to provide three-dimensional scanning and the additional benefit of colorization to aid in discerning differences of uptake. SPECT scanning was performed on 22 patients with interstitial lung disease of various etiologies. Additionally, 7 patients had follow-up SPECT scanning to determine their response to treatment. Two patients are presented as examples.

Aortopulmonary fistula in an infected Dacron graft for coarctation of the aorta: an uncommon cause of hemoptysis.

Hemoptysis secondary to an aortobronchial fistula is rare and uniformly fatal when left untreated. The authors describe a case of massive hemoptysis caused by an aortopulmonary fistula in an infected Dacron graft used successfully to repair a coarctation of the aorta.

Changing strategies in the management of asthma.

Mortality from asthma is apparently on the rise and, in some cases, may be due to the type and amount of medication used by the patient. As a result, the role of some commonly prescribed agents has changed in recent years. In this article, the authors review modifications in the use of currently available drugs, discuss new applications of drugs not traditionally used for asthma, and examine the rationale behind the development of entirely new classes of drugs.

Management of COPD: a physiologic approach.

The main goal of therapy for COPD is to improve the patient's quality of life. A rational approach to therapy requires improvement in pulmonary gas exchange by identification of the type or types of COPD present and tailoring of the therapeutic regimen to the severity and mechanism of obstruction. Other measures can be used to improve tissue oxygenation, including oxygen supplementation, maintenance of cardiac output and tissue perfusion, and reduction of metabolic demands. Complications of COPD are as important as the disease itself in terms of disability and require aggressive therapy.

Obstructive sleep apnea. Warding off the sometimes dire consequences.

Obstructive sleep apnea (occlusion of the upper airway despite continued respiratory muscle activity) is accompanied by increased morbidity and mortality from cardiovascular and cerebrovascular disease. Daytime sleepiness due to the disorder may also be a factor in a higher incidence of automobile accidents in these patients. An overnight polysomnogram is used to confirm the diagnosis and assess severity of physiologic disturbances. Initially, simple measures, such as avoidance of alcohol and sedatives before bedtime and sleeping on the side rather than the back, may be tried. Nasal continuous positive airway pressure is considered first-line therapy, and compliance can be improved by education and counseling of the patient. Uvulopalatopharyngoplasty is beneficial in only 50% of patients. Tracheostomy gives the most consistent long-term benefit but is accompanied by significant emotional morbidity.

The immotile cilia syndrome: explanation for many a clinical mystery.

With the advent of electron microscopy, ciliary abnormalities could be detected, analyzed, and correlated with clinical problems. Kartagener's syndrome, identified over 40 years ago as a triad of sinusitis, bronchiectasis, and situs inversus, was found to actually be a subset of a broader category of diseases: the immotile cilia syndrome. Two other subsets involving multiple organ systems have also been recognized.

Upper airway obstruction due to tuberculosis. Treatment by photocoagulation.

We describe here a case of endotracheobronchial tuberculosis involving both the trachea and major bronchi. Endobronchial carcinoma was suspected initially, even at the time of bronchoscopy. Later, despite improvement of the pulmonary infiltrate and clinical symptoms after chemotherapy, upper airway obstruction occurred. Repeat bronchoscopy showed a distal tracheal nongranulomatous, fibrogranular stenotic lesion. Laser therapy was then employed to reduce the stenosis.

A physician's guide to smoking cessation.

Claims of the effectiveness of smoking cessation services and products are often misleading. It is important that physicians be well informed in order to make appropriate recommendations to their patients who smoke. In this article smoking cessation products and programs are critically evaluated and issues such as cure rates and validation of self-reported abstinence are discussed. Many commercial products are available to aid in cessation, although none has been proven effective. With the exception of nicotine polacrilex gum and transdermal patches in conjunction with a multicomponent clinic, medications are generally ineffective. Smoking cessation programs range from the provision of self-help materials to multisession groups and clinics. Multicomponent, behavioral-based group programs have been the most successful. Physicians should raise the issue of smoking cessation as frequently as possible with smokers and should recommend the use of smoking cessation products and services as appropriate. Referrals should be made to programs that base their success rates on scientifically accepted standards, including a 1-year follow-up, inclusion of dropouts and nonrespondents in calculating outcome, and biochemical validation of self-reported abstinence. Reports of success rates of 80% to 95% at the end of a 1-year program should be viewed with skepticism. Ideally, whether working independently or through referral, the physician should actively promote smoking cessation for all patients who smoke.