Intermittent short-term negative pressure ventilation and increased oxygenation in COPD patients with severe hypercapnic respiratory failure.

With the aim of testing a method that allows increasing concentrations of oxygen to be administered to patients with severe hypoxemia and hypercapnia while avoiding the risk of increasing respiratory acidosis, we studied 17 male patients with advanced chronic obstructive pulmonary disease (COPD) and severe hypercapnic respiratory failure. During 6 h and on one day only, all patients were given intermittent negative pressure ventilation (INPV) together with oxygenation starting at a concentration of 24 percent and increasing to 30 percent. Using this procedure, it was possible to raise arterial PaO2 to safe levels (from 47.2 +/- 3 mm Hg to 61.5 +/- 6 mm Hg, p less than 0.001) without increasing hypercapnia, and a significant drop in PaCO2 levels (from 74.4 +/- 9 mm Hg to 65.6 +/- 12 mm Hg, p less than 0.005) was even observed. One hour after INPV ended, the mean values of PaO2, PaCO2, oxygen saturation, and pH were also significantly better than prestudy values. We conclude that INPV and oxygen therapy with increasing oxygen flow could constitute an alternative option to intubation and mechanical ventilation in cases of severe hypercapnic respiratory failure due to advanced COPD.

[The association of diffuse pulmonary fibrosis and hiatal hernia: a simple coincidence? (author's transl)]. / La asociación de fibrosis pulmonar difusa y hernia del hiato: una simple coincidencia?

Gastroesophageal diseases with reflux can cause numerous pulmonary complications (bronchospasm crisis, bronchitis, pneumonias, lung abscesses). These manifestations are very frequent in the hiatal hernias and in some series have reached up to 46 percent of the cases studied. Recently it has been suggested that microaspirations, repeated over a long period of time, may cause an alteration of the pulmonary interstitium and the consecutive development of a clinical and roentgenologic picture similar to pulmonary fibrosis. The aspirations are produced more frequently at night, favoured by the lying down position and because of it the patients present attacks of nocturnal cough. In this paper, two patients who presented the association of pulmonary fibrosis and hiatal hernia with esophageal relux are described. The first case was diagnosed early; he had minimal radiographic anomalies and the disappearance of the respiratory symptomatology was achieved by means of the medical treatment of the esophageal reflux. The second case was in a very advanced stage with severe respiratory insufficiency and gastrointestinal manifestations of many years' evolution. Both patients had been diagnosed as having idiopathic pulmonary fibrosis. Although there is no experimental proof of the "reflux-fibrosis" theory, we think that this possibility should be kept in mind before diagnosing the interstitial pulmonary pattern as idiopathic, especially in the cases of only slight radiographic and functional involvement susceptible to improvement with correction of the esophageal reflux.

[Pulmonary disease caused by opportunistic environmental mycobacteria. Review of 35 cases]. / Enfermedad pulmonar por micobacterias ambientales oportunistas. Revisión de 35 casos.

The clinical characteristics, radiologic findings, and therapeutic response in 35 cases of pulmonary disease induced by opportunistic environmental mycobacteria collected during a period of 4 years are reported. These cases included 21 infections by Mycobacterium kansasii, 10 by M. xenopi, and 4 by M. avium. The cases reported constituted the 6% of all mycobacterial infections of the lung observed in our institution. The mean age of the patients was 56 years and 83% of them were male. The presence of previous pulmonary involvement was rather frequent, specially the existence of chronic limitation of the air flow (CLAF) (91%) and previous tuberculosis (29%). The clinical symptoms were almost nonspecific and they could frequently be misinterpreted as an intercurrent infection in cases of CLAF. The radiologic findings could not be distinguished from an infection by M. tuberculosis. The clinical course with pharmacologic first line therapy (93% of cases) was satisfactory in 28 patients in whom follow-up controls are available.

Nasal mucociliary clearance in patients with nasal polyposis.

We have studied 30 patients (13 males and 17 females) with nasal polyposis, measuring the nasal mucociliary clearance using the saccharin test. The results have been compared with those obtained in a control group of 20 healthy subjects. The values obtained in the group with nasal polyposis (mean +/- SD = 31.7 +/- 13.4 min) were significantly higher than those of the healthy subjects (mean +/- SD = 12 +/- 6 min; p less than 0.002). These results suggest that there is a significant decrease in the nasal mucociliary clearance of patients with nasal polyposis.

Nomenclature proposal for postsegmental bronchi.

The use of flexible fiberoptic bronchoscopy has given a chance to deeper visualization of the bronchial tree. For this reason, the classical bronchial nomenclature becomes much more annoying when denominating pathological processes located in the most peripheral bronchi. The authors suggest a new nomenclature for an easier and more practical use.

Treatment of pulmonary disease caused by Mycobacterium kansasii: results of 18 vs 12 months' chemotherapy.

SETTING: Chest Clinic, Sant Pau Hospital, Barcelona, Spain. OBJECTIVE: To assess the therapeutic response of pulmonary disease due to Mycobacterium kansasii to 12 and 18 months of chemotherapy. DESIGN: 28 patients with criteria of pulmonary disease caused by M. kansasii not associated with HIV-infection were identified in our department in the period 1985-91 (24 male, 4 female, mean age 56 +/- 12 years). 14 patients were treated with rifampicin-isoniazid-ethambutol daily for 12 months (ethambutol only for the first 6 months), and 14 with the same regimen for 18 months. The follow-up after treatment was 12-30 months. RESULTS: All patients showed improvement of radiographic manifestation of disease and sputum conversion (mean time: 4.5 +/- 2 months). The adverse drug effects were minimal. No failures were detected, and only one patient (3.5%), in the group of 12-month chemotherapy, relapsed after finishing the treatment. CONCLUSIONS: Our findings suggest that pulmonary disease due to M. kansasii has an effective response to 12-month chemotherapy regimen and that it is not necessary to prolong the administration of ethambutol for more than 6 months.

Human tuberculosis due to Mycobacterium bovis: report of 10 cases.

During the period 1986-1990, 10 cases of human disease caused by Mycobacterium bovis were diagnosed in our hospital. The incidence, in relation to the cases of disease from Mycobacterium tuberculosis diagnosed in the same period, was 0.9%. The patients had an average age of 32 years (range 5-68 years). Pulmonary disease was observed in 5 patients (50%), lymphadenitis in 2, pleural effusion in 2 and peritoneal in 1. The most significant of the epidemiological features was that 2 patients were veterinary students. There was 1 death from ovarian neoplasia with abdominal dissemination. The other cases responded favourably to treatment with standard chemotherapy of 6-12 months achieving cure, without relapse, of all the patients.

[Primary and initial bacterial resistances in tuberculosis patients at a general hospital, 1983-1987]. / Estudio de las resistencias bacterianas primarias e iniciales en enfermos tuberculosos de un hospital general durante 1983-1987.

From july 1982 to december 1987 we prospectively evaluated the primary resistance (PR) of 248 strains of M. tuberculosis isolated from patients with several clinical forms of tuberculosis. The results were compared with those of a similar study carried out between 1978-1982. PR persisted relatively stable with time, although it showed a trend towards reduction. Isoniazide resistance (4.8%) still has a leading epidemiological interest. The 89% of strains showed isolated resistance to a single drug. Only two strains had associated resistance to INH and SM. Strains with PR to RIF, ETB or PZA were not detected. Of the 248 evaluated strains, 32 were isolated from intravenous drug abusers with AIDS. Only one of these strains had a low level (0.2 mg/l) PR to INH. At last two of these drug abusers developed acquired resistance to INH and ETB-RIF, respectively. Considering the difficulty to control chemotherapy in this group of patients, our finding has a considerable epidemiological interest.