Cause and evaluation of chronic dyspnea in a pulmonary disease clinic.

To test whether, in patients with chronic dyspnea, a diagnostic approach based on objective confirmation of suspected diagnoses would be superior to one based on clinical impression alone, we prospectively studied 85 patients with a primary complaint of dyspnea seen in a pulmonary subspecialty clinic. We achieved 100% success in determining the causes of dyspnea compared with only 66% accuracy based on clinical impression alone. Four groups of disorders, asthma, chronic obstructive pulmonary disease, interstitial lung diseases, and cardiomyopathy accounted for two thirds of the cases. Findings on the history and physical examination were too nonspecific to determine the specific diagnosis. Pulmonary function testing, including a methacholine bronchoprovocation challenge, were the most useful diagnostic tests, particularly for chronic obstructive pulmonary disease and asthma. Chest roentgenogram was most useful for interstitial lung disease, and comprehensive exercise testing for dyspnea due to psychogenic factors or deconditioning. Specific therapy was effective in reducing or eliminating dyspnea in the majority of cases. We conclude that a diagnostic approach to chronic dyspnea based on objective findings and verification, rather than clinical impression alone, will consistently lead to an accurate diagnosis and an improved therapeutic outcome.

The clinical implications of bilaterally abnormal impedance plethysmography.

Although impedance plethysmography (IPG) is a test of recognized value in the diagnosis of acute proximal deep venous thrombosis (DVT), its meaning in patients with bilaterally abnormal IPGs is unclear. Consequently, we sought to determine the clinical significance of the bilaterally abnormal IPG in hospitalized patients. In a five-month prospective study, 19% (81/425) of all IPGs done at our institution were bilaterally abnormal (55% of all abnormal IPGs). Acute proximal DVT was found in 26% (14/53) of patients with bilaterally abnormal IPGs who underwent further diagnostic testing. Thirty-five percent of the patients with DVT were found to have either bilateral lower extremity DVT or clots in the inferior vena cava. A numerical score, the venous function index (VFI), was computed for the 101 legs for which further definitive diagnostic evaluations for DVT had been completed. The mean VFI of seven for legs with acute proximal DVT was significantly less than the mean VFI of 13 for legs with no DVT. Fifty percent of legs with a VFI less than or equal to five had DVT, whereas only 7% of legs with a VFI greater than 15 had DVT. The bilaterally abnormal IPG is a common clinical occurrence, is frequently associated with acute DVT, and the VFI is helpful in discriminating legs with acute proximal DVT from normal legs in patients with a bilaterally abnormal IPG.

Asthma: better outcome at lower cost? The role of the expert in the care system.

Asthma is a common disease for which morbidity and mortality have been increasing. This despite advances in the scientific understanding of asthma and in the pharmacologic armamentarium available to treat it. The dichotomy between knowledge and outcomes led us to review asthma from a systems perspective. We have presented data first to document failure in the current system of care and then to examine factors associated with improved outcomes. We found a disparity in outcome and costs when care given by experts was contrasted with care given by generalists. We conclude that "expert-based" care systems are superior from the perspective both of the patient and of the insurer; medical outcomes are better at lower overall cost. Managed care companies are in a unique position to identify asthmatics and to shift them from generalist to expert-based care when appropriate.

Transtracheal aspiration. Guidelines for safety.

A four-year experience with transtracheal aspiration was reviewed in order to determine those patients at risk for developing life-threatening complications. One hundred procedures were performed by at least 20 different physicians trained according to an established protocol. Complications were limited to minimal subcutaneous emphysema in 19 percent (10/52), pneumomediastinum in 3 percent (3/93), and gross but self-limited hemoptysis in 1 percent (one patient); occasional unifocal premature ventricular contractions were noted in one patient. We conclude that patients not at risk of developing life-threatening complications from transtracheal aspiration can be identified. They (1) are able to cooperate and have a clearly identifiable and normal cricothyroid membrane, (2) have the procedure performed only by well-trained or supervised physicians, (3) have an arterial oxygen pressure of at least 70 mm Hg with administration of supplemental oxygen, and (4) have a prothrombin activity of at least 65 percent of the control value or a normal bleeding time or a platelet count of at least 100,000/cu mm. To minimize subcutaneous emphysema or pneumomediastinum, no patient should have therapy with intermittent positive-pressure breathing or any other procedure that might induce coughing for the subsequent 24 hours.

Music improves patient comfort level during outpatient bronchoscopy.

STUDY OBJECTIVE: To determine the effect of music during bronchoscopy on patient perception of the procedure. DESIGN: Prospective randomized trial. SETTING: University-based bronchoscopy suite. PATIENTS: Twenty-one patients received music (M+), and 28 patients served as controls (M-). MEASUREMENTS AND RESULTS: Physiologic responses, subjective patient perceptions, and administered medications were monitored. After the procedure, the technician and the physician both rated their impression of the patients' comfort levels to see how accurately they correlated with actual patient reports. There was no difference in physiologic responses between the M+ and M- groups. The M+ patients reported significantly greater comfort (p = 0.02) and less cough (p = 0.03) than the M- group, while there was no difference in reported dyspnea P = 0.21). Both physicians and technicians were very inaccurate in their assessments of patient level of comfort. Medications given did not differ for the two groups. CONCLUSION: Music during bronchoscopy is a simple and inexpensive nonpharmacologic way to improve patient comfort.

Primary testicular choriocarcinoma with pulmonary metastases presenting as ARDS.

We report a case in which ARDS was the presenting manifestation of testicular choriocarcinoma with numerous metastases to the lungs. We also review the literature on other cases in which ARDS developed as a result of neoplastic infiltration of the lungs and stress the fact that it may be indistinguishable from ARDS from other causes. Because potentially effective chemotherapy for the neoplastic processes most commonly involved (ie, germ cell tumors, acute leukemia and lymphoma) is available, we emphasize the importance of considering a neoplastic disorder in the differential diagnosis of cases of otherwise unexplained ARDS. Early accurate diagnosis could conceivably result in an improved outcome in these cases.

The lack of a role for saline solution inhalation in bronchoprovocation challenge.

The purpose of this study was to look prospectively at the practice of prefacing methacholine bronchoprovocation challenge (BPC) with diluent challenge using physiologic saline solution (NaCl) as the diluent. We wished to determine whether NaCl challenge added to the safety or diagnostic accuracy of BPC. We studied 108 consecutive patients undergoing methacholine BPC. We determined (1) the FEV1 response of all patients to the inhalation of NaCl (the difference between the FEV1 before NaCl and the FEV1 after NaCl), and (2) the correlation between the response to saline solution and bronchial hyperresponsiveness (BHR) measured using methacholine. Paired Student's t testing demonstrated a small but significant difference between the values for FEV1 before and after NaCl for the group as a whole (n = 108; mean change, -0.9 +/- 4 percent [+/- SD]; p = 0.023). When the mean changes in the FEV1 after NaCl for the group with increased BHR (BHR+) (n = 62; mean, -1.1 +/- 4.9 percent) and the group with no increase in BHR (BHR-) (n = 46; mean, -0.6 +/- 2.4 percent) were contrasted, there was no significant difference between the two groups (p = 0.46). Only 4 of 108 patients had a drop in FEV1 of 10 percent or more after NaCl, with the greatest drop being 16 percent. All four patients were BHR+, but none had marked BHR. For the BHR+ group, there was no correlation between response to saline solution and subsequent response to methacholine (r = 0.02). We conclude that saline solution challenge adds time and expense to BPC without increasing the safety or yield of BPC. We suggest that NaCl challenge can be omitted from the standard performance of BPC.

Bronchodilator reversal of bronchospasm and symptoms incurred during methacholine bronchoprovocation challenge. Documentation of safety and time course.

We undertook a prospective study of bronchoprovocation challenge (BPC) to look at issues of safety and reversibility of bronchospasm and symptoms induced by BPC. Over a 14-month interval, we documented 62 consecutive cases of bronchial hyperresponsiveness. During BPC, there was a statistically significant but clinically modest increase in both cough and dyspnea. Both bronchospasm and symptoms were readily reversed with a simple protocol of inhaled albuterol using a metered-dose inhaler with a spacer. Routine protocol was effective in every case; there was never a need for individualized physician intervention. Our prospective data document the safety of BPC; we could find no reason why BPC would need to be confined to the hospital. We conclude that BPC is a valuable clinical test which merits wider dissemination and use.

The role of sinus imaging in the treatment of chronic cough in adults.

PRIMARY STUDY OBJECTIVE: To determine the appropriate role and timing of sinus imaging studies in the evaluation and treatment of chronic cough. DESIGN: Prospective study of chronic cough. All patients underwent sinus imaging, the results of which identified prospectively the following: (1) fluid in sinuses, with or without opacification, and (2) mucosal thickening. Patients then were treated using an algorithm that sequentially addresses the etiologies of chronic cough. Patients whose sinus imaging studies had demonstrated fluid were treated initially for sinusitis, but mucosal abnormalities alone were not considered an indication to change the algorithm. After workup, relationships between abnormalities on sinus imaging studies and diagnoses were determined. SETTING: University hospital pulmonary outpatient clinic. PATIENTS: Thirty-six patients (31 women, 5 men; mean age, 58.4 years). Cough duration averaged 5.2 years (range, 4 weeks to 30 years). RESULTS: Diagnoses were made in 100% of patients, and cough resolved in 86%. Mucosal thickening correlated with sinusitis as a cause of cough in only 29% of cases. CONCLUSIONS: Mucosal thickening is not diagnostic of sinusitis as a cause of chronic cough; in most patients, cough will resolve without treatment for sinusitis. Given this lack of specificity, it is reasonable to delay sinus imaging until after efforts at treating rhinitis have failed and, in the absence of complaint or findings of postnasal drip, until after completion of evaluation for asthma. The principles of diagnosis and treatment of chronic cough remain simple: go sequentially from the most common to the least common cause; use tools that begin with the most available and least expensive and invasive modality; then move as needed to tools that are more expensive and invasive.

Inpatient management of status asthmaticus.

We examined physician management of patients hospitalized for status asthmaticus at a university hospital. A retrospective review of consecutive admissions for status asthmaticus covering a 13-month period yielded 130 charts for review. We found that practice patterns with respect to documentation of severity of illness, medications, and documentation of efficacy of therapy fell short of the current state of knowledge with respect to treatment of asthma. Asthma is a treatable disease, and physician education needs to bridge the gap between current practice patterns and standards of optimal therapy as defined in the literature.

Chronic cough as the sole manifestation of Hodgkin's disease.

A patient presented with a cough of three months' duration as the sole manifestation of mediastinal Hodgkin's disease. Systematic evaluation resulted in prompt diagnosis and specific successful treatment of both the Hodgkin's disease and the cough. This case emphasizes that specific therapy based upon an accurate diagnosis almost always results in effective treatment of chronic cough.

The physiologic effects of inhaled amphotericin B.

Our institution used an experimental protocol for the use of inhaled amphotericin B as a prophylactic measure to prevent fungal disease in severely immunocompromised patients. We did a prospective study of the physiologic effects of amphotericin B administration. We looked specifically at oxygen saturation levels, peak flow values, and symptoms of patients given amphotericin B. We collected data on a series of 18 patients and of 132 amphotericin B administrations. Four (22%) of the patients stopped treatments because of nausea and vomiting which were believed to be due to the inhaled amphotericin B. For the remaining patients, no treatment was stopped because of symptoms or physiologic changes caused by amphotericin B, although there were 9 instances of clinically significant bronchospasm as defined by a drop in peak flow of 20% or more, 9 clinically relevant increases in cough, and 3 clinically relevant increases in dyspnea. Forty-eight percent of the clinically relevant changes occurred in patient 8. Another 16% occurred in asthmatic subjects who were significantly more likely (p = 0.03) to experience a 20% or more drop in peak flow than were patients without asthma. The physiologic profile of the response to inhaled amphotericin B is acceptable.

Bloody pleural effusion associated with an intralobar pulmonary sequestration.

A 50-year-old male cigarette smoker with a posterior parenchymal lung mass developed a bloody, exudative pleural effusion. Pathologic examination of the resected lung confirmed the preoperative diagnosis of an intralobar pulmonary sequestration.

Diagnosis of bronchial asthma by clinical evaluation. An unreliable method.

To determine the predictive value of wheeze compared to methacholine inhalation challenge (MIC) in diagnosing asthma, we prospectively evaluated 34 patients considered to be difficult diagnostic problems, referred with a history of wheeze. On the basis of MIC results, 12 patients had hyperreactive airways consistent with asthma, while 22 had airways that were no more reactive than those of normal controls. Compared to MIC, a history of wheeze was predictive of hyperreactive airways 35 percent of the time, a prior clinical diagnosis of asthma 62 percent, and scattered monophonic expiratory wheeze 43 percent. We conclude that: (1) a history of wheeze, a prior clinical diagnosis of asthma, and expiratory wheezing on physical examination are much less reliable than MIC in predicting the presence or absence of asthma; (2) these parameters cannot be used as reliable epidemiologic markers for asthma; and (3) the clinical suspicion of asthma should be confirmed by bronchoprovocation challenge or the demonstration by spirometry of reversible expiratory airflow obstruction.

The effect of transtracheal aspiration on cardiac rate and rhythm. A prospective study.

To determine the effect of transtracheal aspiration (TTA) on cardiac rate and rhythm, we prospectively monitored by electrocardiography 14 cases before, during, and after the procedure. No serious or life-threatening arrhythmias occurred; sinus tachycardia was virtually a routine occurrence. Cardiac rate increased significantly from an average of 96 beats/min before the procedure to an average of 121/min during the procedure (P less than 0.001). The incidence of premature ventricular or atrial contractions did not change significantly before, during, or after the procedure. Before TTA, all patients had PaO2 measurements equal to or greater than 70 mm Hg; none had CO2 retention or an unstable cardiac status. Patients with significant COPD (mean FEV1/FVC% = 48) were not at increased risk for cardiac arrhythmias during or immediately after TTA. Our results imply the following: (1) routine ECG monitoring in patients such as ours undergoing TTA does not appear to be necessary; and (2) premedication with narcotics, sedatives, or atropine does not appear to be warranted.

Chronic persistent cough: an uncommon presenting complaint of thyroiditis.

We report two patients with non-conventional thyroiditis whose chief complaint was chronic persistent cough. Cough was attributed to thyroiditis only after extensive diagnostic evaluations failed to uncover another cause and only after cough and thyroiditis disappeared simultaneously with suppressive therapy for the latter. Although thyroiditis is a rare cause of persistently troublesome cough, the diagnosis can be made by systematic evaluation of the sites of receptors and afferent nerves subserving the cough reflex.

Respiratory care practitioners' attitudes toward patients with AIDS.

OBJECTIVE: To assess attitudes of respiratory care practitioners about AIDS and patients with AIDS. DESIGN: A questionnaire that explored attitudes about AIDS was disseminated throughout southern New Jersey. Identity of individual responders was protected carefully. RESULTS: One hundred fifty-nine responses were received. The majority of responders favored identification of patients with AIDS, segregation of those patients into AIDS wards, and then avoidance of the AIDS wards. There was some bias against patients with known high-risk behaviors (especially drug abuse), but once a patient had AIDS the fear of getting AIDS was the only factor that correlated (p = 0.001) with the desire to avoid AIDS patients. Thirty-nine percent of responders said that they used universal precautions less than 90 percent of the time, and no factor (including fear of AIDS and markers of education) predicted which therapists did not consistently use them. CONCLUSIONS: The desire to avoid AIDS represents a rational desire not to become infected with the HIV virus. This study documents an identify-and-avoid philosophy in lieu of careful use of universal precautions. Educational efforts need to emphasize that the use of precautions represents the only truly effective means of preventing infection with the AIDS virus and other communicable diseases.

Comparison of wire-guided and nonwire-guided radial artery catheters.

OBJECTIVE: To determine if either wire-guided-catheters (WGC) or nonwire-guided catheters (non-WGCs) are associated with a higher rate of successful arterial cannulation overall or when evaluated by a variety of patient and operator characteristics. DESIGN: Prospective clinical trial in a ten-bed adult medical-surgical ICU in a 500-bed university hospital. PATIENTS: Adults requiring arterial cannulation for hemodynamic monitoring or frequent blood sampling. A total of 116 attempted arterial cannulations were recorded, and 112 in 67 patients were acceptable for statistical analysis. RESULTS: Overall, no difference in success rates could be demonstrated between WGC and non-WGC. WGCs were associated with a higher success rate in patients with pulses characterized as absent or weak (78% vs 37%; p=0.01). WGCs also had a greater success rate than non-WGCs for more experienced operators, whether defined by seniority (83% vs 44%; p=0.02) or by experience at arterial catheterization (81% vs 48%; p=0.02). CONCLUSION: WGCs were not associated with better success rates overall than were non-WGCs, although there were higher success rates in several subsets of patients and/or operators. Because of their significantly higher costs, WGCs cannot be recommended for routine use for arterial catheterization. In cases where successful catheterization is essential, however, there are circumstances under which they may be the preferred equipment, depending on patient characteristics and operator experience.

Chronic cough as the presenting symptom of oculopharyngeal muscular dystrophy.

A patient had chronic, persistent cough as the presenting symptom of the neuromuscular disorder oculopharyngeal dystrophy (OPD). The presence of a significant smoking history initially resulted in the cough incorrectly being attributed to COPD. By using a systematic diagnostic approach, the correct etiology was determined.

Postnasal drip causes cough and is associated with reversible upper airway obstruction.

We prospectively evaluated nine patients with cough from postnasal drip for evidence of extrathoracic upper airway obstruction. Patients compared before treatment to normal control subjects had physiologic evidence of extrathoracic upper airway obstruction; their mean FIF50%/FEF50% and FIF25-75%/FEF25-75% ratios of 0.88 and 0.98 were significantly less than the values in control subjects of 1.28 and 1.37 (p less than 0.001). With specific therapy, postnasal drip decreased, cough disappeared and upper airway obstruction physiologically and physically resolved in all patients. We conclude that: 1) when postnatal drip is causally associated with cough, flow-volume loops can provide objective documentation of this clinical association; 2) flow-volume loops can be used as an objective method in comparing the efficacy of different therapeutic agents for cough due to postnasal drip; and 3) normal predicted values of extrathoracic airway function should not include measurements from patients who have recently recovered from cough associated with postnasal drip.