Kinin generation in acute pneumonia and chronic bronchitis.

Kinins are potent inflammatory mediators, liberated from kininogens by different kininogenases. The aim of this study was to investigate the kinin generation pathways in acute and chronic inflammation of the lower airways. We studied bronchoalveolar lavage fluid (BALF) of patients with acute pneumonia, patients with chronic bronchitis and healthy controls. Kinins were determined by radioimmunoassay (RIA). Plasma kallikrein (pl-Kal), alpha2-macroglobulin (alpha2-M) and toluenesulphonylarginine methyl ester (TAME) esterase activity (TAME-ea) were studied in BALF before and after gel filtration chromatography. Plasma kallikrein and alpha2-M were measured using two newly developed sandwich enzyme-linked immunosorbent assays (ELISAs). TAME-ea was measured by a radiochemical assay. After gel filtration, inhibition of TAME-ea with benzamidine, soy-bean-trypsin inhibitor (SBTI) and aprotinin was performed. Kinins and TAME-ea did not differ significantly between acute pneumonia and chronic bronchitis, whereas pl-Kal and alpha2-M values were significantly higher in acute pneumonia. Gel filtration revealed the highest TAME-ea peak in acute pneumonia corresponding with the first alpha2-M peak at approximately 800 kDa, whereas in chronic bronchitis the highest peak was found at approximately 40 kDa. The inhibition test showed that the TAME-ea peak at approximately 800 kDa was due to pl-Kal and the TAME-ea peak at approximately 40 kDa was mainly due to tissue kallikrein. High peaks of alpha2-M and pl-Kal were found in pneumonia and only small peaks were seen in chronic bronchitis. We conclude that in acute airway inflammation kinins seem to be mainly generated by plasma kallikrein whereas in chronic inflammation, kininogenases other than plasma kallikrein, such as tissue kallikrein, seem to be more important.

[Restless legs syndrome and periodic leg movements during sleep in patients with sleep apnea--a therapeutic problem?]. / Restless-legs-Syndrom und periodische Beinbewegungen im Schlaf bei Patienten mit Schlafapnoe--ein therapeutisches Problem?

Restless-legs syndrome and periodic movements during sleep are associated with sleep apnoea syndrome. Similar to sleep apnoea syndrome, restless-legs syndrome and periodic movements during sleep may cause severe hyposomnia and hypersomnia. Exact diagnosis may partly fail in severe obstructive sleep apnoea syndrome if only cardiorespiratory polygraphy is performed. Simultaneous videorecordings and EMG of mm. tibialis ant. ensure diagnosis. Therapeutic regime may be difficult due to failure or side effects, however. We report on our experience in an one-year follow-up of 12 patients with sleep apnoea syndrome and restless-legs syndrome and/or periodic movements during sleep. Despite adequate interdisciplinary initiation of therapy and monitoring, these patients are often subject to therapy changes, failures or side effects. There was no correlation between jerks and the complaints of the patients.

[Effect of long-term oxygen therapy on sleep architecture in patients with severe dilated cardiomyopathy and Cheyne-Stokes respiration]. / Einfluss einer Sauerstofflangzeittherapie auf die Schlafarchitektur bei Patienten mit schwerer dilatativer Kardiomyopathie und Cheyne-Stokes-Atmung.

Patients suffering from severe heart failure may develop breathing disorders during sleep. Results may be heavy disturbances in sleep architecture, worsening of haemodynamics and of the prognosis of these patients. Causes of breathing disorders are probably instability of breathing regulation caused by hypoxaemia, hypocapnia, and prolonged blood circulation time. This study examined the influence exercised by different concentrations of continuously applied oxygen during night time on breathing disorders, oxygen saturation and sleep architecture in patients with severe heart failure (NYHA III-IV). All patients showed an improvement in sleep architecture. Total sleeping time increased significantly. Fragmentations of sleep by arousal reactions decreased, time of REM-sleep and non-REM-sleep III and IV increased significantly.

[Change in bronchial hyperreactivity with nCPAP respiration in patients with sleep related respiratory disorders]. / Anderung der bronchialen Hyperreagibilität unter nCPAP-Beatmung bei Patienten mit schlafbezogenen Atmungsstörungen.

Own results of 23,174 patients suffering from sleep apnoea syndrome showed that about 4 per cent of these patients have an increase of bronchial reactivity. In 60 patients with assured bronchial hyperreactivity we performed an inhalative bronchial provocation test using carbachol. Tests were performed before and after two days of treatment with nCPAP in the early morning. 23 of our 60 patients showed a decrease of PD20 FEV1 after nCPAP. The other patients did not show any significant differences. Our results demonstrate that in patients with increased bronchial reactivity, nCPAP therapy may aggravate bronchial hyperreactivity.

[Effect of n-CPAP therapy on outcome of cold provocation]. / Einfluss der n-CPAP-Therapie auf den Ausfal der Kälteprovokation.

Our own investigations comprising 23,174 patients suffering from sleep apnoea showed that about 4 per cent of these patients suffer from a hyperreactive bronchial system. In some of these patients treatment with nCPAP causes coughing or mild dyspnoea even after having been previously asymptomatic. Loss of water and heat on the surface of bronchial mucosa may induce reversible bronchoconstriction. We examined in 60 patients suffering from obstructive sleep apnoea whether mechanical treatment with nCPAP would cause a change in bronchial reactivity. Cold air hyperventilation was used in provocation testing. Provocation tests were performed before and after a 3-day treatment with nCPAP in the early morning. In some patients with previously positive reaction, application of nCPAP alone decreased the lung function. Cold air hyperventilation challenge may be helpful to detect possible risks in patients using nCPAP, and to minimise such risks.

Central sleep apnea.

A central apnea is a disorder characterized by apneic events during sleep with no associated ventilatory effort. Central sleep apnea syndrome is characterized by repeated apneas during sleep resulting from loss of respiratory effort. Although the etiology of central apnea remains obscure in most cases, current investigations into breathing control system during sleep and association with certain diseases have pointed out possible mechanisms. Ventilation during sleep is highly dependent on the nonbehavioral control system. As a result, any diseases affecting this control system could influence the breathing patterns while the patient is asleep. As our results show, most patients with central sleep apnea and without congestive heart failure had quantifiable abnormalities like diminished carbon dioxide response curves. Neurological diseases affecting the brainstem are able to produce breathing pattern disorders in sleep. Well-known neurological diseases such as arteriosclerosis in the elderly, infarctions, tumors, hemorrhage, accidents with damage of this region, encephalitis, poliomyelitis or other infectious diseases may cause central apnea during sleep, even if in wakefulness no abnormalities of breathing patterns are present. Apneas cause hypoxemia, hypercapnia and increased sympathicotonia. This may result in development of pulmonary artery hypertension or systemic hypertension. Published results demonstrate that medical treatment is ineffective in these patients. Implantation of a diaphragm pacing device is an invasive measure, the efficacy of the diaphragm pacing has not been proven by long-term trials, however. Mechanical ventilation was shown to be the most efficient treatment. A therapeutic procedure using a timed n-BiPAP device is able to normalize blood gases during sleep. The n-BiPAP prevented the development of severe pulmonary artery hypertension during sleep.

[Evaluating physical fitness after unilateral lung transplantation with ergometry and blood gas analysis]. / Beurteilung der körperlichen Leistungsfähigkeit nach einseitiger Lungentransplantation mittels Ergometrie und Blutgasanalyse.

7 patients aged 30-56 years with the perception of subjective increased fitness 4-22 months after single lung transplantation were tested for the objective benefit. Using a standardized ergometric test protocol cardiopulmonary parameters (ventilation, blood gases, gas exchange, blood pressure, ECG) were measured 5 males and 2 females. After transplantation in all patients the objective fitness was increased by 30-60 watts and the blood gases were markedly improved. The physical fitness of the subjects under study was probably limited by the reduced lung function of the native lung, the reduced mobility of the diaphragm in elderly patients and the impaired muscular strength and endurance.

[The effect of nCPAP respiration on hyperreactivity in patients with sleep related respiratory disorder]. / Der Einfluss der nCPAP-Beatmung auf die Hyperreagibilität bei Patienten mit schlafbezogener Atmungsstörung.

Of the 8,973 patients with sleep related breathing disorders examined in our department, about 4% were found to have a hyperreagible bronchial system. Provocation tests were performed before and after a 3-day CPAP therapy in 8 male patients with confirmed bronchial hyperreagibility. Two of these 8 patients revealed a marked increase of the respiratory path resistance and a decrease in FEV1.0 of 30% in the provocation test after 3 days. This did not occur with the other patients. From these findings, it is concluded that CPAP therapy can lead to an increase in the hyperreagibility in some patients with hyperreagible bronchial systems. However, further investigations are needed to identify the underlying causal relationships.

[Effect of n-BiPAP therapy on the hemodynamics in patients with central sleep apnea]. / Einfluss einer n-BiPAP-Therapie auf die Hämodynamik bei Patienten mit zentraler Schlafapnoe.

We report of five patients, suffering from central sleep-apnea. All patients had a global respiratory failure during day-time and developed severe pulmonary artery hypertension during sleep. Therapy with n-BiPAP leeds to an improvement of blood gases and a decrease of pulmonary artery hypertension during sleep.

[Effect of n-CPAP therapy on the 24-hour blood pressure profile in severe obstructive sleep apnea syndrome]. / Einfluss der n-CPAP-Therapie auf das 24-Stunden-Blutdruckprofil bei schwerem obstruktiven Schlafapnoe-Syndrom.

We examined circadian blood pressure rhythm before and two days after onset of n-CPAP therapy in 50 patients, suffering from polysomnograhpically ensured severe obstructive sleep-apnea-syndrome. Measurements were performed using a non-invasive blood pressure registration. Patients with normal circadian blood pressure conditions and those with disturbed circadian rhythm could be differentiated. N-CPAP therapy may normalize circadian blood pressure conditions in some patients.

[Polysomnographic results before and after uvulopalatopharyngoplasty (UPPP)]. / Polysomnographische Ergebnisse vor und nach Uvulo-Palato-Pharyngo-Plastik (UPPP).

Uvulo-palato-pharyngo-plastic is one possibility for treatment of obstructive sleep-apnea. We examined in a prospective study design 36 patients, suffering from polysomnographically ensured obstructive sleep-apnea-syndrome, who were undergone uvulo-palato-pharyngo-plastic. We analysed pre- und postoperative polysomnographic data. Most of patients demonstrated a decrease of amount of apneas, duration of apneas and an increase of minimal oxygen-desaturation. Patients who had high amounts of apneas (AI > 40/h) or who had a Broca-index > 140 p.c. gained not as much from surgical treatment as other patients did.

[Theophylline acceptance in long-term therapy of patients with obstructive sleep related respiratory disorder]. / Theophyllinakzeptanz in der Langzeittherapie bei Patienten mit obstruktiver schlafbezogener Atmungsstörung (OSAS).

In 1,150 patients with sleep apnea syndrome, the apnea number, the morning theophyllin level, the symptom of morning exhaustion were recorded for the first night of theophyllin therapy and in the follow-up period of up to 5 years; in addition, side effects were noted at the end of the observation period. Prior to start of the therapy, the average apnea number was 97 per night; this decreased to 25 per night in the initial therapy. In the observation period of between 3 and 28 months, the number of apnea phases increased slightly on average. The symptoms of morning exhaustion initially decreased to 60% but increased again by about 20% over the next five years. In responders, theophyllin reduces the number of apnea in the long term course; however, frequent therapy controls are needed to determine the optimal dosage. Longitudinally, patients with an apnea index < 20/profited most from this drug therapy.

[Polysomnographic study before and after uvulopalatopharyngoplasty]. / Polysomnographische Untersuchung vor und nach UPPP.

Polysomnography measurements were performed before and 8 weeks after surgery (UPPP). Most of the cases showed a decrease in the number and duration of apnoea phases. Oxygen saturation increases.

[Long-term results with nasal CPAP ventilation therapy in obstructive sleep apnea]. / Langzeitergebnisse unter einer Therapie mit nasaler CPAP-Beatmung bei der obstruktiven Schlafapnoe.

In 410 patients suffering from severe sleep-apnoea syndrome long-term observation was done (0.5-4 years). Treatment with CPAP-breathing normalised haemodynamic disorders. Only 1 patient discontinued the therapy. In 30% an increase of CPAP pressure and in 2% an decrease of the CPAP pressure was necessary.

[Long-term treatment of sleep apnea with evening administration of oral retard theophylline]. / Langzeitbehandlung der Schlafapnoe mit einer abendlichen Gabe von oralem retardierten Theophyllin.

In 776 patients suffering from sleep apnoea long-term treatment with sustained-release theophylline was investigated. Responders show a significant reduction of apnoea phases. Using an individual theophylline dosage with morning theophylline concentrations between 5 and 8 micrograms/ml, only few side effects occurred. Positive effects on cardiopulmonary capacity were seen.

[Effect of nasal positive pressure ventilation in patients with dilated cardiomyopathy (NYHA III-IV)]. / Einfluss der nasalen Uberdruckbeatmung bei Patienten mit dilatativer Kardiomyopathie (NYHA III-IV).

5 patients suffering from dilatative cardiomyopathy (NYHA III-IV) were investigated by polysomnography, haemodynamics and CPAP-BIPAP-breathing. In 4 patients IPAP-breathing with 6 cm H2O resulted in better haemodynamics.

[Long-term follow-up of patients with central apnea]. / Langzeitbeobachtung bei Patienten mit zentraler Apnoe.

This is a report on 297 patient with central asphycia. The patients were divided into three groups according to the blood gases. 21 patients were in group three. 16 patients died due to right heart failure. In group one and two no patients died. In group one spontaneous remissions were seen.

[Pleural diseases in magnetic resonance tomography (MRT)]. / Pleuraerkrankungen in der Magnetresonanztomographie (MRT).

MR images of 48 patients with histologically confirmed benign and malignant diseases of the pleura were retrospectively compared with CT and bioptically/surgically obtained findings. In 47/48 patients pathological changes of the pleura were visualized by increased signal intensities on T2-weighted and contrast enhanced T1-weighted MR images. This lead to a slightly improved sensitivity compared to CT, where pathological pleura findings were confirmed in 45/48 patients. MRI was able to identify 24/28 confirmed pleural effusions, whereas CT was successful in 26/28 patients. In two cases effusions not identified on CT were visible on T2-weighted MRI. 4 pleural effusions were missed with MRI.. On CT images differentiation of pleural changes vs effusions or adjacent lesions of lung parenchyma was successful in 20/28 and in 17/23 cases, respectively. Contrast enhanced T1-weighted images achieved the highest diagnostic accuracy with 22/28 and 20/23 cases, respectively. Signal intensities on MRI were unsuitable as sole criterion for the differentiation of benign and malignant diseases of the pleura. Contour and pattern of spreading of pleural changes were helpful in differential diagnosis. Nodular changes, thickening of more than 10 mm and mediastinal, circumferential and entire hemithoracic affection of the pleura were suggestive for malignant pleural disease. Infiltration of the diaphragm and the chest wall were most indicative for malignancy; here MRI (2/2 resp. 18/19 cases) was superior to CT (0/2 resp. 14/19 cases). CT was superior in the detection of pleural calcifications and osseous destruction.(ABSTRACT TRUNCATED AT 250 WORDS)