Drug treatment of asthma in the elderly.

Asthma is a chronic inflammatory disease of the airways that may affect individuals at any age, and can be especially challenging to diagnose and treat in the elderly. The hallmarks of asthma--bronchial hyperreactivity and reversible airflow obstruction--lead to symptoms of intermittent wheezing, dyspnoea and cough. Occasionally, atypical symptoms such as chest pain or tightness occur and may mimic other diseases more common in the elderly, such as ischaemic heart disease. It is therefore important to use objective measures such as spirometry or bronchoprovocation testing to make a diagnosis. In recent years, trends in the treatment of asthma have changed from reliance on shorter-acting bronchodilating drugs to long term preventative therapy with inhaled corticosteroids. In some elderly asthmatic patients, symptoms may be mild and intermittent, and treatment with an inhaled beta 2-adrenergic agent may be all that is required. Most, however, experience persistent symptoms, and pharmacological therapy should begin with daily inhaled corticosteroids and be increased in a stepwise fashion according to the patient's needs. In such patients, short-acting beta 2-agonists should be continued as needed for acute symptomatic relief. Longer-acting beta 2-agonists, oral theophylline and inhaled anticholinergic therapy may be useful. When symptoms are more severe and potentially life-threatening, oral corticosteroids should be given. Since elderly patients are more likely to develop complications of asthma therapy and more likely to manifest adverse interactions with other therapeutic agents, more intense monitoring of asthma treatment is required in dealing with this population.

The regulation of normal lung function.

The regulation of breathing is dependent on the complex interaction of three components of the respiratory system: 1) the control centers, 2) the sensors, and 3) the effector organs. The control centers reside in the brainstem and are responsible for the automaticity of breathing. Input into these respiratory centers can be initiated from higher brain centers in order to produce voluntary breathing efforts. Afferent neural signals also come to the central control system from the respiratory sensors, which are divided into two categories: chemoreceptors and sensory receptors. The chemoreceptors respond to changes in the blood oxygen, carbon dioxide, and hydrogen ion concentration by sending impulses to the control center to alter the ventilatory pattern by affecting the effector organs--the respiratory muscles. The sensory receptors are located in the upper and lower airways, the lung, and the muscles of respiration. They also can have a marked effect on the respiratory pattern. It is believed that stimulation of these receptors is important in the initiation of hyperventilation and cough in lung diseases such as asthma. There is also recent evidence that respiratory chemoreceptor responsiveness is abnormal in patients with asthma who have a history of near-fatal attacks.

Asthma in the elderly patient.

Epidemiologic surveys have shown increased morbidity and mortality for asthma, especially in the elderly population. Although the majority of patients with asthma have their onset of disease as children or young adults, new-onset asthma may occur at any age, even in the eighth and ninth decades. When asthma begins at an advanced age, symptoms are typical of young adults, but medication requirements to maintain normalcy are often high.

Primary pulmonary hypertension in the elderly.

Primary pulmonary hypertension is usually considered a disease of younger adults. We reviewed the natural course of primary pulmonary hypertension in patients aged 65 years or greater. During an 8-year period, 63 elderly patients were discharged from our hospital with a diagnosis of pulmonary hypertension. In eight instances, an elevated mean pulmonary arterial pressure (greater than 25 mm Hg) could not be explained by secondary causes. These elderly patients with primary pulmonary hypertension had symptoms common to younger patients with this disease, including dyspnea (eight patients), chest pain (five), pedal edema (four), and fatigue (one). In all but one patient, the initial diagnosis was incorrect, and the patients were thought to have more common diseases of the elderly that cause similar symptoms. Coexisting medical problems were common and further obscured the correct diagnosis. Survival was significantly shorter in those patients with symptoms of less than 6 months' duration. Primary pulmonary hypertension should be considered in the differential diagnosis in elderly patients with unexplained dyspnea and chest pain.

Pneumatic chest wall compression. A cause of respiratory failure from massive subcutaneous emphysema.

Subcutaneous emphysema rarely causes significant adverse clinical consequences. Two patients had development of massive subcutaneous emphysema during positive-pressure ventilation that resulted in chest wall compression and respiratory failure. Drainage of the subcutaneous air produced dramatic improvement. Subcutaneous emphysema is potentially fatal in ventilated patients. Specific decompression of subcutaneous tissues is indicated in such extreme cases.

Asthma in the elderly. A comparison between patients with recently acquired and long-standing disease.

To characterize asthma in the elderly, 25 consecutive nonsmoking pulmonary clinic patients over the age of 70 who met the American Thoracic Society criteria for asthma were identified. Of these, 12 patients (48%) had developed asthma at an advanced age (greater than 65 yr). This group with late-onset asthma had a mean duration of disease of 5.1 +/- 2.5 yr. The remaining group with early-onset asthma had a mean duration of illness of 31.4 +/- 14.6 yr. On the day of evaluation each patient underwent pulmonary function testing off all medication for at least 12 h. These two groups were indistinguishable by symptoms and medication requirements. Immediate hypersensitivity skin testing to 43 aeroallergens was uniformly negative in all 25 patients but the histamine control was always positive. IgE levels in both groups were not different from those in elderly control subjects. Those with early-onset asthma had a greater likelihood of previous allergic disease (p less than 0.001) and a significantly greater degree of airflow obstruction in pre- and postbronchodilator pulmonary function testing (p less than 0.05). This study suggests that long-standing asthma may lead to chronic persistent airflow obstruction and thereby mimic chronic bronchitis and emphysema (COPD).

Intensive care of status asthmaticus. A 10-year experience.

Previous reports have disclosed a high morbidity and mortality in hospitalized asthmatics, especially those treated in the intensive care unit. Recently, it has been questioned whether the benefits of treating asthmatics in the intensive care unit outweigh the potential hazards. To address this issue, we examined the outcome of status asthmaticus in our medical intensive care unit between January 1, 1978, and December 31, 1987. Eighty episodes of status asthmaticus occurred in 64 patients. In 50 episodes, respiratory failure (PaCO2 greater than 50 mm Hg) was present. In half of these episodes, mechanical ventilation was avoided despite severe acidosis and hypercapnia; in the remainder mechanical ventilation was required as a lifesaving measure. Most patients improved rapidly and required only a short stay in the intensive care unit. There were no deaths and few complications. This was accomplished by close monitoring and repetitive blood gas analysis. We believe that the previous high complication rates and mortality associated with the hospital care of status asthmaticus can be avoided.

Unilateral lung hyperinflation and herniation as a manifestation of intrinsic PEEP.

In a 64-year-old ventilated patient with severe chronic obstructive pulmonary disease and extensive unilateral pneumonia, intrinsic PEEP became recognized when the chest roentgenogram showed unilateral lung hyperinflation and herniation of a large bulla to the contralateral hemithorax. The use of an on-line suction catheter may have contributed to the development of intrinsic PEEP. Removal of the catheter resulted in roentgenographic and clinical improvement.

The clinical spectrum of Staphylococcus aureus pulmonary infection.

Staphylococcus aureus causes serious pulmonary infections in adults. Prior descriptions of this entity have depended on diagnosis of expectorated sputum cultures that are often contaminated. To better characterize this infection, we retrospectively reviewed the medical records of 31 adults with S aureus pulmonary infection diagnosed by culture specimens uncontaminated by the upper respiratory flora. Our results support the concept that S aureus pulmonary infections usually occur in older adults (sixth decade or older) with concomitant illnesses that are typically nosocomial. However, in contrast to previous reports, the chest roentgenograms in these patients typically showed multilobar infiltrates (60 percent), predominantly in the lower lobes (64 percent), and often bilateral (48 percent). Pleural involvement (48 percent) was more common than previously reported, and abscess formation (16 percent) occurred infrequently. Sputum cultures were found to be sensitive but nonspecific diagnostic tools. Despite antibiotic therapy, reinfection occurred in 10 percent of patients and the mortality rate was 32 percent.

Changes in airway resistance following nasal provocation.

Controversy exists on whether stimulation of the nasal mucosa results in reflex bronchoconstriction. To address shortcomings in previous experimental design, we performed double-blind randomized nasal challenges in asthmatic patients with allergic rhinitis and in controls. Using pledgets containing 10-microliters aliquots of 0.9% saline or increasing concentrations of methacholine or histamine, we were able to increase nasal resistance significantly in both groups. Only methacholine caused an increase in lower airway resistance, and this could be blunted by premedication of the nasal mucosa with phenylephrine. This suggests that the effect on lower airway resistance was due to systemic absorption. Our study does not support the existence of a nasobronchial reflex from mechanical alteration of the nasal mucosa.

High frequency of atopic asthma in a pulmonary clinic population.

Seventy-two consecutive adult asthmatic patients seen in the Pulmonary Clinic at Rhode Island Hospital were tested for atopy by prick test with 14 standard aeroallergens and by in vitro total and specific IgE determinations (FAST). A total of 58.3 percent of patients were found to be atopic by these tests. There was a significant difference between the mean total serum IgE in atopic and nonatopic asthma and in atopic asthma and control subjects. The age onset was lower in atopic asthmatic patients, and they were more likely to have a history of chronic rhinitis than nonatopic subjects. Family history of rhinitis or asthma and severity of asthma was not different between the two groups. Since our outpatient facility has a large allergy clinic in proximity to the pulmonary clinic, which was the source of our patient population, this investigation has a negative bias toward allergy. Nevertheless, this study reveals that atopy is common in adult asthmatic patients, and a battery of allergy tests (skin tests or in vitro tests) together with total serum IgE is able to differentiate between atopic and nonatopic asthma.

Fibrinolysis in critically ill patients.

Impaired fibrinolysis may contribute to development of adult respiratory distress syndrome (ARDS). Pathologic increases in endogenous plasminogen activator inhibitor (PAI-1) may blunt normal fibrinolysis and unmask alternate fibrinolytic mechanisms, such as elastase-induced fibrin degradation. We measured PAI-1 and elastase-induced fibrin(ogen) degradation products in 69 critically ill patients in our medical intensive care unit (MICU) and in nine healthy volunteers. Factor VIII-related antigen protein (VIII:Ag), a reported marker of acute lung injury, and alpha-1-protease inhibitor (alpha-1-PI), an acute phase reactant, were also measured. MICU patients included 24 control patients with no known risk of ARDS, 35 patients with risk factors for ARDS including sepsis, pneumonia, aspiration, and shock, and 12 patients with ARDS including two patients from at-risk groups who developed ARDS. Plasma PAI-1 was determined by chromogenic assay, elastase-induced peptides by a new radioimmunoassay, VIII:Ag by immunoelectrophoresis, and alpha-1-PI by immunodiffusion. When compared to normal volunteers, MICU control patients had elevated PAI-1, VIII:Ag, elastase-induced peptides, and alpha-1-PI. Patients with ARDS had significantly higher PAI-1 and VIII:Ag than did MICU control patients; elastase-induced peptides and alpha-1-PI were not higher. However, at-risk patients who did not develop ARDS also had high PAI-1 or VIII:Ag. Although these data cannot refute the possible role of these compounds in the pathogenesis of ARDS, they demonstrate that PAI-1 and VIII:Ag may be elevated in many critically ill patients but may not be useful markers for the subsequent development of ARDS.

Bronchoprovocation testing.

Bronchial hyperresponsiveness is a constant feature of asthma even when airflow obstruction is absent. Detecting nonspecific bronchial hyperresponsiveness is useful when the diagnosis of asthma has not been confirmed or when a patient describes symptoms of cough, chest tightness, and dyspnea that cannot be ascribed to other causes. Also, because wheezing is a symptom of other disorders, inhalation challenge tests can be useful in defining its cause when reversible airflow obstruction has not been documented. A number of easy and safe techniques are available to detect nonspecific bronchial hyperresponsiveness. The histamine and methacholine challenge have had the most widespread use in the clinical pulmonary function laboratory. The exercise and cold air challenges are limited by expense. The osmotic challenge may gain more acceptance as experience with this technique grows. These different agents have the advantage of simplicity, reproducibility, a low number of adverse effects, and a high degree of specificity and sensitivity. A limited number of asthmatics show bronchial hyperresponsiveness to specific agents such as chemical sensitizers in the workplace, aeroallergens, aspirin, nonsteroidal anti-inflammatory agents, and sulfiting agents. Bronchoprovocation testing with these agents is usually reserved for the hospital laboratory because severe or delayed reactions may occur. These tests, however, can be extremely useful in defining a population of sensitive asthmatics.

Rapid development of cor pulmonale following acute tonsillitis in adults.

We describe two adult patients in whom acute tonsillitis resulted in the rapid development of cor pulmonale in the absence of clinically evident upper airway obstruction or diffuse obstructive airway disease. Both patients had developed symptoms of sleep apnea and all-night polysomnography confirmed the presence of severe obstructive sleep apnea. These cases emphasize the potentially severe cardiovascular consequences of acute tonsillar hypertrophy in the obese adult patient.

A home monitoring system for nasal CPAP.

A compact portable sensing system (PSS) was developed for home monitoring of patients with obstructive sleep apnea treated with nasal continuous positive-airway pressure (CPAP). The system consisted of a solid-state pressure sensor connected with plastic tubing to the side port of the nasal CPAP mask, a power supply, and a strip chart recorder. The device was validated against standard polysomnography in ten patients with obstructive sleep apnea undergoing overnight nasal CPAP trials. A total of 397 apneas and hypopneas were observed in the ten patients. The PSS device detected 386 events (sensitivity, 97.2 percent). In addition, there were 29 false positive events noted by the device (positive predictive value, 93 percent). The device was then tested at home in 23 patients on nasal CPAP. Eight of these patients had persistent apneas requiring adjustment of their CPAP pressure. The PSS device allowed for accurate reevaluation of nasal CPAP settings in the patient's home without necessitating expensive, time-consuming in-hospital laboratory polysomnographic studies.

Hemoptysis during sexual intercourse. Unusual manifestation of coronary artery disease.

Sexual activity increases physiologic demands on the cardiovascular system. A patient with stable angina pectoris experienced recurrent bouts of hemoptysis caused by left ventricular failure that occurred only during sexual activity. Severe atherosclerotic coronary vascular disease was confirmed by cardiac catheterization. The patient underwent successful coronary artery bypass grafting; nine months after surgery, he is sexually active and symptom-free.