Addition of anticholinergic solution prolongs bronchodilator effect of beta 2 agonists in patients with chronic obstructive pulmonary disease.

A randomized, double-blind placebo-controlled clinical trial was designed to assess the safety, efficacy, and duration of the bronchodilation resulting from the addition of 500 micrograms of ipratropium bromide (Atrovent; Boehringer Ingelheim, CT) inhalation solution to standard small volume nebulizer treatments with 2.5 mg albuterol inhalation solution. A total of 195 patients (63% men, average age 64 years) with > 10 pack-year smoking histories and stable, moderate-to- severe chronic obstructive pulmonary disease (COPD; forced expiratory volume in 1 second [FEV1] 1.02 liter, 38.8% predicted) from eight university-affiliated chest clinics in seven U.S. cities were enrolled into the study. Asthma, rhinitis, and eosinophilia were exclusions, as was daily use of > 10 mg of prednisone (or 20 mg on alternate days). There was a 2-week stabilization period during which the patients were instructed in the use of the small volume nebulizers, which they used three times daily with albuterol alone. They were asked to keep daily logs of peak flow rates, pulmonary symptoms, and additional medication usage. On their test day 1 the subjects came to the pulmonary function laboratory having been off theophylline for 24 hours and beta 2-agonists for 12 hours and performed a baseline spirometry. They then received their morning small volume nebulizer treatment of albuterol to which was added either 500 micrograms if ipratropium bromide or a saline placebo. Spirometry was repeated at 15, 30, and 60 minutes, and then hourly for 8 hours. Subjects then took home a 2-week supply of albuterol and test drug for thrice daily use in their small volume nebulizer. They were evaluated for pulmonary symptoms and adverse effects every 14 days. The 8-hour spirometry was repeated on test day 43 and finally on test day 85. Primary data evaluated were the peak increase in FEV1 and the area between the FEV1 baseline value and the 8-hour FEV1 curve. Similar calculations were made for forced vital capacity (FVC) and 25-75% forced expiratory flow (FEF25-75%). On test day 1 the peak increase in FEV1 for the ipratropium bromide + albuterol subjects was 26% greater than those on placebo + albuterol (p < 0.003). The area under the 8-hour FEV1 curve was 64% greater in those given ipratropium bromide on test day 1 (p < 0.0002). Similar increases were seen in FVC and FEF25-75%. The peak improvements in FEV1 and FVC with the addition of ipratropium bromide to albuterol were maintained on test days 43 and 85. Considering the safety and efficacy profiles of this combination, the data would suggest that ipratropium bromide inhalation solution should be considered first-line therapy for those patients with COPD requiring small volume nebulizer treatments.

Unusual manifestations of thoracic actinomycosis.

Actinomycosis is a chronic, suppurative bacterial infection characterized by multiple abscesses, sinus tracts, fibrosis, and granulation involving the face, neck, thorax, or abdomen. Thoracic actinomycosis probably results from aspiration of oropharyngeal secretions. Its description in the literature is extensive. Reported herein are two cases of thoracic actinomycosis with unusual manifestations exemplifying the organism's lack of regard for fascial planes. The authors present a comprehensive review of actinomycosis in order to encourage early diagnosis. The importance of bedside examination and inspection of available material stained by Gram's method are emphasized. Computed tomography scanning is a useful adjunct for assessing the anatomic extent of this disease.

Postviral bronchial hyperreactivity syndrome: recognizing asthma's great mimic.

Although there are no prospective studies regarding the frequency of postviral bronchial hyperreactivity syndrome, it is a common complication of upper and lower respiratory tract viral infections. The respiratory symptoms closely resemble those of asthma, but they are present for only 3 weeks to 3 months following the acute infection phase. Defining the mechanisms of this syndrome may provide insight into the pathogenesis of asthma. Postviral bronchial hyperreactivity syndrome is frequently misdiagnosed and inappropriately managed because many physicians are unfamiliar with this illness. Because of its characteristic history, diagnosis is straightforward when the physician knows what to look for, and response to therapy is excellent. This report presents a case history followed by a review of the proposed mechanisms of bronchial hyperreactivity following viral respiratory infections. The clinical features and criteria for diagnosing postviral bronchial hyperreactivity syndrome are also discussed.