Ipratropium bromide in asthma. A review of the literature.

In comparative studies of asthma, ipratropium bromide has been shown to have a slower onset of bronchodilator action but a longer duration of effect than beta agonists. An additive effect of ipratropium and beta agonists has been demonstrated, in addition to prolongation of the bronchodilator response. Most studies do not show a definite difference in responsiveness of atopic versus nonatopic asthmatic patients; there are, however, reports indicating a greater responsiveness to anticholinergic agents than to beta agonists in patients with chronic bronchitis and emphysema. Ipratropium has been shown not to affect mucociliary clearance, sputum volume, or viscosity. It effectively inhibits the bronchial response to methacholine and, to a lesser degree, to histamine, serotonin, bradykinin, and antigen. Protection against exercise-induced asthma with this drug has been variable, but ipratropium has been found particularly useful in psychogenic asthma. Its role in occupational asthma remains to be determined.

Recognition and treatment of adult respiratroy distress syndrome secondary to viral interstitial pneumonia.

Four cases of adult respiratory distress syndrome secondary to viral interstital pneumonia were treated successfully. The illnesses started with a prodrome of upper respiratory symptoms. The development of dyspnea was a key symptom from which point respiratory failure developed within 24 to 48 hours. Chest roentgenograms showed alveolar infiltrative patterns which later became coalescent. The clinical course consisted of fever, dyspnea, hypoxia and acidosis, There was no response to therapy with antibiotics, 100 per cent oxygen by mask and intermittent positive pressure breathing (IPPB) over the first 24 hours. Supportive therapy then initiated included endotracheal intubation, the administration of humidified oxygen by volume cycled respirator with positive end expiratory pressures of 10 to 15 cm H2O and corticosteroids. It is concluded that early recognition of the syndrome, coupled with prompt insituition of aggressive supportive respiratory management may be lifesaving in patints with severe interstitial pneumonia.

Early detection of hypersensitivity pneumonitis in office workers.

Symptoms of hypersensitivity pneumonitis in three employees in an office building led to an investigation of their work environment. An open spray water air cooling system was implicated when inhalation challenge with the spray water caused acute illness in one of them. A questionnaire survey of the 4,023 co-workers identified 48 other suspect cases, and laboaratory studies confirmed hypersensitivity pneumonitis in three additional workers of this group. A significant change in pulmonary function, occurring only after exposure to the work environment, was the most useful laboratory finding and was found in five workers with no other pulmonary abnormalities, but not is asymptomatic workers or controls, since five of the six patients with hypersensitivy pneumonitis worked in offices cooled by the spray water system and since three had positive responses to inhalation challenge, use of the spray water system was discontinued. The affected workers improved after they were removed from the office complex.

The pathophysiologic and roentgenologic effects of chest irradiation in breast carcinoma.

We studied the effects of radiation therapy on lung function in 21 patients who underwent modified radical mastectomy and radiotherapy for breast carcinoma. The patients had pulmonary function studies and chest X rays prior to radiation therapy and at six weeks, and three, six, and twelve months following radiation therapy. All pulmonary function studies showed a small but statistically significant decline within the first three months following radiation therapy. Changes in the moderate and large airways continued to occur after three months. None of the changes in pulmonary function were reversible. Radiographic changes occurred in 12 patients. These changes occurred later than the lung function changes (median time for the changes was twelve months) and were unrelated to changes in lung function.

Childhood hypersensitivity pneumonitis due to dove antigens.

A case of hypersensitivity pneumonitis due to doves is reported and compared with other cases due to dove or pigeon antigens reported in children. The diagnosis is substantiated by the presence of precipitating antibody to dove and pigeon serum, clinical improvement after contact with the doves was broken, and a positive response to inhalation challenge with pigeon serum. The insidious nature of this disease is emphasized as well as the importance of having detailed environmental information in children with unexplained respiratory disease.

Bronchial hyperreactivity and cough due to angiotensin-converting enzyme inhibitors.

Seventeen patients using angiotensin-converting enzyme (ACE) inhibitors for hypertension were evaluated with baseline spirometry followed by determination of bronchial reactivity by challenge with methacholine. There were nine coughers and eight noncoughers in the study. Among the nine coughers, eight demonstrated bronchial hyperreactivity. Conversely, none of the noncoughers disclosed bronchial hyperreactivity. Eight of the nine coughers were rechallenged two to six months following cessation of ACE inhibitor therapy. Six of these eight showed persistent bronchial hyperreactivity. We conclude that cough is associated with the use of ACE inhibitors in patients with underlying bronchial hyperreactivity. The findings indicate caution in administration of ACE inhibitors in asthmatic patients and those with known bronchial hyperreactivity.

Value of in situ elemental microanalysis in the histologic diagnosis of silicosis.

Pulmonary specimens obtained from ten normal subjects and 53 patients with various pulmonary diseases were studied with energy-dispersive x-ray analysis. The amount of silicon in the pulmonary tissue was determined and expressed as a silicon/sulfur (Si/S) ratio. This Si/S ratio was below 0.2 in the ten normal subjects and in 14 patients who had various interstitial pulmonary diseases but had no previous history of exposure to silica or other dusts known to cause pulmonary fibrosis. The Si/S ratio was greater than 0.3 in 19 of 22 patients who had a history of exposure to silica dust and had clear-cut histologic evidence of silicosis. The Si/S ratio was less than 0.2 in 12 and between 0.2 and 0.3 in two of the 14 patients who had a history of exposure to silica dusts but no clinical or histologic evidence of silicosis. We conclude that the determination of the silicon content of tissue by energy-dispersive x-ray analysis is useful in separating the fibrosis due to silicosis from the other causes of pulmonary fibrosis.

Antigen-induced enhancement of bronchial reactivity.

Bronchial hyperreactivity as determined by the airway response to methacholine was evaluated pre- and post-antigen challenge in three patients with specific antigen sensitivity. No significant change in pulmonary function was noticed after inhalation of antigen alone. However, transient but significant increase in methacholine responsiveness followed the antigen challenge. The studies indicate a need for a nonspecific inhalation challenge following a negative antigen challenge when clinically indicated.

Airway response to hair spray in normal subjects and subjects with hyperreactive airways.

Short-term 20-second exposure to hair sprays A and B failed to show significant decreases in maximum expiratory flow rates at low pulmonary volumes in normal subjects; however, significant decreases were observed with hair spray B in eight subjects with hyperractive airways (abnormal response to inhalation of methacholine). On the partial flow-volume curves, flows at 40 percent and 25 percent of forced vital capacity decreased 8.9 to 10.3 percent and 14 to 18.7 percent, respectively. The hair sprays differed in their content of perfume and plasticizer, and since the latter is generally considered nontoxic at room temperature, the perfume may be the responsible agent. It would appear from this study that normal healthy individuals are at little risk, at least from brief exposure to hair spray; however, in the presence of hyperreactive airways, as seen in asthmatic subjects and in some people with allergic rhinitis and viral respiratory infections, an immediate response of the airways may result from exposure to some hair sprays.

Sarcoidosis in hypersensitivity pneumonitis.

An abnormal chest x-ray film showing hilar adenopathy, diffuse interstitial pulmonary infiltrations, or both, combined with a tissue biopsy revealing noncaseating granuloma, are suggestive of sarcoidosis; however, non-caseating granuloma may also be found in other forms of pulmonary disease. Immunologic and environmental evaluation of three patients with the diagnosis of sarcoidosis made by the above criteria, revealed hypersensitivity pneumonitis in all. Since therapeutic considerations in these two diseases are different (avoidance being the mainstay in hypersensitivity pneumonitis), all methods to ensure a correct diagnosis should be employed.

Pulmonary artery thrombolysis and stenting after a bilateral sequential lung transplantation.

Bilateral sequential lung transplantation was complicated by pulmonary artery anastomotic stenosis and bilateral pulmonary thromboemboli. Pulmonary artery thrombus was eliminated by intrathrombotic but not by systemic administration of urokinase. The pulmonary emboli resulted in localized pulmonary infarctions, supporting the need for thrombolytic intervention to restore pulmonary perfusion in the absence of collateral bronchial blood flow after lung transplantation. Pulmonary artery stenosis was relieved by endovascular stenting, avoiding an early reoperative procedure. This case suggests that direct administration of thrombolytic agent may be superior to intravenous administration in the treatment of pulmonary thromboemboli. Pulmonary arterial anastomotic stenoses after lung transplantation can be relieved by endovascular procedures.

A new mask filter cartridge used to determine applicator inhalation exposure to an alachlor herbicide (Lasso) during normal spraying operations.

A filter cartridge with a low air-flow resistance was designed for use on a modified half-face respirator worn during the application of alachlor (Lasso) herbicide. The filter trapped large concentrations of alachlor while retaining the ability to trap small respirable droplets. Moreover, alachlor could be recovered from the disassembled cartridge and analyzed by conventional methods. The test cartridges were used in combination with conventional personal air samplers to determine whether the filters trapped more alachlor when compared with personal samplers and to determine accurately the amount of alachlor reaching the breathing zone. Farmers sprayed alachlor in the form of alachlor (N = 7) or alachlor mixed with other herbicides or surfactant (N = 15). An average of 4 x 10(-2) mg or 2 x 10(-4) mg/kg of applied alachlor reached the respirator filters. This concentration was 10-fold higher than the alachlor recovered from the personal samplers. The new filter cartridge is better for determining the amount of alachlor reaching the breathing zone, and there is a low potential for significant inhalation exposure to alachlor during normal spraying operations.

The spectrum of respiratory disease associated with exposure to metal working fluids.

Occupational respiratory diseases have been reported following exposure to metal working fluids. We report a spectrum of respiratory illnesses occurring in an outbreak in 30 workers of an automobile parts engine manufacturing plant. Workers presented with respiratory complaints and, after clinical and laboratory evaluations, were classified as those having hypersensitivity pneumonitis, occupational asthma, or industrial bronchitis, or those without occupational lung disease. Hypersensitivity pneumonitis affected seven workers, with six exhibiting serum precipitins to Acinetobacter Iwoffii. Occupational asthma and industrial bronchitis affected 12 and six workers, respectively. Oil-mist exposures were below current recommendations. Gram-negative bacteria, but no fungi, Thermophiles, or Legionella, were identified. Although specific agents responsible for each individual case could not be identified, probably both specific sensitizing agents and non-specific irritants from metal working fluids, additives, or contaminants contributed to this spectrum of occupational respiratory illness.

Environmental challenge.

A variety of organic dusts and chemicals encountered in our environment are capable of provoking a response in the lung. Frequently, they produce transient or reversible physiologic changes that may obscure the diagnosis. The patient may fail to recognize a causal relationship with a specific exposure with late-onset reactions and the development of symptoms remote from the exposure. A thorough evaluation of the individual's total environment and symptoms, with particular reference to their time course, is essential in making the diagnosis. Removal of the worker from a suspected environment, with serial clinical and physiologic monitoring to demonstrate improvement, or return to the workplace with similar studies, can be helpful in establishing a causal relationship. When a specific agent can be identified, a controlled inhalation challenge in the laboratory is the procedure of choice. Once a causal relationship has been established, the individual should be removed from exposure or the implicated agent eliminated.

Spectrum of clinical disease in pulmonary infection with Mycobacterium avium-intracellulare.

Cases of infection with Mycobacterium avium-intracellulare reported in Milwaukee, Wisconsin, have become more common in recent years, and their incidence--50 cases per year--is now similar to that of tuberculosis. Cases usually occur in middle-aged men with underlying lung diseases, but variations in age, sex, presentation, and severity of disease are wide. Several cases that illustrate pathogenesis and spectrum of disease, from primary, to chronic-active, to healing stages, are presented. The disease tends to run an indolent course in most cases, but extensive disease and unfavorable early course indicate poor prognosis. At a 10-year review, mortality had reached sizable numbers in this aging population with frequent serious underlying problems. Only a small number of these deaths can be attributed directly to mycobacterial disease.

Bathtub refinisher's lung: an unusual response to toluene diisocyanate.

Immunologic and inhalation challenge studies were performed on a patient engaged in bathtub refinishing who developed systemic and respiratory symptoms suggestive of hypersensitivity pneumonitis temporally related to his occupation. The refinishing process used a catalyst containing toluene diisocyanate, and all clinical features of the disorder were reproduced by challenge. No immunologic mechanism could be identified. A change of occupation resulted in complete relief of symptoms.