Physician estimation of FEV1 in acute exacerbation of COPD.

There have been recent recommendations to include objective measurements of airway obstruction in the treatment of patients with acute asthma. These recommendations are based in part on the inaccuracy of physicians in estimating airways obstruction in asthmatic patients. The purpose of this study was to evaluate the ability of physicians to estimate the degree of airways obstruction in patients with acute exacerbation of COPD. We studied 90 patients. The physicians were able to estimate the percent of predicted normal FEV1 to within 10 points only 38 percent of the time prior to treatment and 46 percent of the time posttreatment. Forty-nine percent of the patients whom the physicians believed had an improvement in pulmonary function with treatment actually did not improve, while 31 percent of the patients who the physicians believed did not improve their pulmonary function with treatment actually did improve. We conclude that physicians' estimates of the degree of airway obstruction in acute exacerbation of COPD are inaccurate. Assessment of patients in the emergency department presenting with COPD should be based on objective measurements of pulmonary function.

The natural history and clinical findings in undifferentiated abdominal pain.

STUDY OBJECTIVE: This was a follow-up study of patients diagnosed in and discharged from the emergency department with undifferentiated abdominal pain to establish the natural history of this condition and to define clinical features of patients with undifferentiated abdominal pain. SETTING: ED of a county teaching hospital. DESIGN: Telephone survey of patients at two to three days (first contact) and again at two to three weeks (second contact) after discharge and retrospective chart review. TYPE OF PARTICIPANTS: All patients 18 years or older discharged with the primary diagnosis of undifferentiated abdominal pain from the ED. Excluded were pregnant patients and those presenting with trauma. Patients unavailable for follow-up contact were not included in further data analysis. MEASUREMENTS AND MAIN RESULTS: Four hundred three patients were discharged from the ED with undifferentiated abdominal pain. Of these, 307 (76.1% were available for follow-up information. The female-to-male ratio was almost 3:1. At first contact, 26.8% of all patients were pain-free and another 30% improved. At second contact, 59.1% had no pain, and an additional 28.6% reported improvement. Ten patients were hospitalized during the follow-up period for continued abdominal pain, and no deaths were attributed to abdominal conditions. The largest subgroup of patients with undifferentiated abdominal pain was female patients less than 30 years old. Epigastric pain was the most common patient complaint, with nausea second. The abdomens of most patients were nontender on examination. Abnormal laboratory and radiologic findings in patients with undifferentiated abdominal pain were few. CONCLUSION: Patients with the diagnosis of undifferentiated abdominal pain have a benign short-term course. Almost 88% of patients were pain-free or improved by two to three weeks after their evaluation. No signs or symptoms clearly identified subgroups of patients with undifferentiated abdominal pain.

A randomized, controlled comparison of isoetharine and albuterol in the treatment of acute asthma.

STUDY OBJECTIVE: To determine whether treatment of acute asthma with repeated doses of nebulized albuterol leads to greater bronchodilation and lower hospital admission rate than treatment with nebulized isoetharine. DESIGN: Randomized, double-blinded, controlled trial of albuterol and isoetharine. TYPE OF PARTICIPANTS: Patients between 18 and 50 years old presenting with acute asthma. Patients were excluded if they had a history of sensitivity to the study drugs, had congestive heart failure or chronic-obstructive pulmonary disease, or were unable to perform spirometry. One hundred three patients were entered into the study. INTERVENTIONS: All patients received oxygen and methylprednisolone in addition to administration of either isoetharine or albuterol. The nebulized aerosol was given at hourly intervals for a total of three doses. MEASUREMENTS AND MAIN RESULTS: Spirometry was performed before treatment and again at 90 and 180 minutes. Initial forced expiratory volume at one minute (FEV1) was 38.1% of predicted normal for the albuterol group and 36.0% of predicted normal for the isoetharine group. At 180 minutes, FEV1 was 55.6% of predicted normal for the albuterol group and 57.1% of predicted for the isoetharine group (NS). Twenty-eight percent of the albuterol group required admission compared with 26% of the isoetharine group (NS). There was no difference in occurrence of side effects between the two groups. CONCLUSION: Repeated doses of albuterol do not lead to a greater improvement in pulmonary function or a lower hospital admission rate than treatment with isoetharine.

Spirometric criteria for hospital admission of patients with acute exacerbation of COPD.

Recent studies have demonstrated that there is a high relapse rate for patients discharged from the Emergency Department (ED) following treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD). Objective criteria have not been established to determine when to hospitalize these patients. This study evaluated spirometric criteria for that use. Eighty-three patients with an acute exacerbation of COPD were studied; 45 percent were admitted to the hospital while 17 percent of the patients who were discharged suffered a relapse. An FEV1 of less than 40 percent of predicted normal identified patients who required hospital admission or suffered a relapse with a sensitivity of 0.96, specificity of 0.58, and overall accuracy of 0.78. Combining clinical assessment with spirometry led to an improvement in specificity to 0.73 with a minimal decrease in sensitivity. Patients with an FEV1 of 40 percent or greater of predicted normal or no clinical evidence of respiratory distress after treatment may be safely discharged from the hospital. Patients not meeting these criteria are at high risk for relapse and should either be admitted or have further aggressive ED therapy.

Theophylline concentrations in patients with acute exacerbation of COPD.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) frequently report a history of theophylline use prior to arrival in the emergency department. The reliability of using this history to guide aminophylline therapy is, however, unclear. The authors studied patients with an acute exacerbation of COPD to determine the relation between the initial theophylline level and the medication history. Seventy-nine patients with a mean age of 64.3 years were entered into the study. The average theophylline level was 10.8 micrograms/mL. Forty-seven percent of the patients had subtherapeutic levels, 46% had therapeutic levels, and 7% had toxic levels. There were weak although statistically significant correlations between the theophylline level and the interval since the last theophylline dose (r = -.40, P less than .001), as well as with the last recorded outpatient theophylline level (r = .45, P less than .001). However, the theophylline level could not be predicted accurately in a number of patients. The authors conclude, because the prediction rule was often inaccurate, aminophylline therapy in patients with acute exacerbation of COPD should be based on direct measurement of the serum theophylline level.

A prospective study of femoral versus subclavian vein catheterization during cardiac arrest.

Femoral vein catheterization has advantages over subclavian vein catheterization during cardiac arrest in that there is minimal interference to ongoing CPR. In addition, risks of subclavian catheterization are not a factor in femoral vein catheterization. Few studies have compared the success rate for catheterization of one site with that of the other during cardiac arrest. We conducted a prospective study to compare the success and complication rates for femoral with those of subclavian vein catheterization. Ninety-four patients undergoing CPR had either femoral or subclavian vein catheters placed during the course of the arrest. Catheter placement was verified by injection of radiopaque contrast material. We found that the success rate for femoral catheterization was 77% compared with a success rate of 94% for subclavian vein catheterization (P less than .05). There were no instances of pneumothorax with subclavian vein catheterization. There was no apparent learning curve leading to an increased success rate during the course of the study. We conclude that femoral vein catheterization should not be used except in those instances where attempts at peripheral and central venous cannulation are unsuccessful.

Relationship between arterial blood gases and spirometry in acute exacerbations of chronic obstructive pulmonary disease.

Previous studies have established spirometric criteria for arterial blood gas analysis during acute asthmatic attacks. However, only general guidelines have been available regarding the need for blood gas analysis during an acute exacerbation of chronic obstructive pulmonary disease (COPD). We conducted a study to determine the relationship between arterial blood gases and spirometry in 70 emergency department patients during acute exacerbations of COPD. Arterial blood gas analysis and spirometry were performed on arrival at the emergency department. All of the patients with a pCO2 of more than 45 mm Hg had an FEV1 of less than 35% of the predicted normal. We found patients with a pO2 of less than 60 mm Hg who had an FEV1 as high as 54% of the predicted normal. There was no correlation between the FEV1 and pO2. Because spirometry was not reliable for identifying patients with significant hypoxemia, we conclude that arterial blood gas analysis is indicated for patients presenting to the ED with acute exacerbations of COPD. Spirometric criteria that have been used to eliminate the need for arterial blood gases in asthmatic patients cannot be applied safely to patients with COPD.

A randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD.

We conducted a randomized, controlled double-blind study to determine whether intravenous administration of methylprednisolone early in the therapy for acute exacerbations of COPD would improve pulmonary function in the Emergency Department and reduce the need for hospitalization. Ninety-six patients completed the study. All were at least 50 years of age and had no history of asthma. Patients received aminophylline and hourly administration of aerosolized isoetharine. Methylprednisolone (100 mg) or physiologic saline solution was given within one-half hour of arrival in the Emergency Department. Spirometry was performed initially and after the third and fifth aerosol treatments. We found no greater improvement in FEV1 in the group receiving the steroid (37 percent) than in the control group (43 percent; NS). There was also no difference in the rate of hospitalization (33 percent in the steroid-treated group vs 30 percent in the control group; NS). We conclude that early administration of methylprednisolone does not affect the emergency phase of treatment for acute exacerbations of COPD.

Effects of C apoproteins on the activity of endothelium-bound lipoprotein lipase.

Rat apoprotein C-II activated the hydrolysis of triacylglycerol in apoprotein-depleted chylomicrons by lipoprotein lipase in vitro and in the perfused rat heart. Apoproteins C-I and C-III-3 inhibited the hydrolysis of the triacylglycerol moiety in intact and apoprotein C-II-re-activated chylomicrons in vitro, but had no effect on the hydrolysis in situ.

Action of liproprotein lipase on apoprotein-depleted chylomicrons.

1. Rat lymph chylomicrons were exposed to soluble and to immobilized trypsin. This treatment caused no detectable changes in the chylomicron structure or lipid composition, but did result in virtually total depletion of all their tetramethylurea-soluble apoproteins. 2. The capacity of these apoprotein-depleted chylomicrons to act as substrate for lipoprotein lipase in vitro and in situ (i.e. isolated perfused rat heart) was decreased by about 90 and 75% respectively, compared with intact chylomicrons. 3. On incubation with rat plasma high-density lipoproteins, trypsin-treated chylomicrons readily acquired a full apoprotein complement. This resulted in the complete restoration of their capacity to act as substrate for lipoprotein lipase both in vitro and in situ. 4. It is suggested that with the use of try,sin-treated chylomicrons it is now possible for the first time to investigate the physiological role that individual apoproteins play in the catabolism of triacylglycerol-rich lipoproteins by lipoprotein lipase.