Outpatient oxygen therapy in chronic obstructive pulmonary disease. A review of 13 years' experience and an evaluation of modes of therapy.

Thirteen years' experience with home oxygen for patients with advanced chronic obstructive pulmonary disease are reviewed. Home oxygen is safe and relieves pulmonary hypertension and elevated RBC mass in some, but not all patients. Marked clinical improvement is the most important result of long-term home oxygen use, including reduced hospitalizations and return to gainful employment for a few patients. Chronic compensated carbon dioxide retention is well tolerated and adaptive in cases of severe chronic airflow obstruction. New oxygen concentrators are effective in correcting hypoxemia and may make home oxygen administration more convenient and less expensive.

Decreased hypoxic ventilatory drive in the obesity-hypoventilation syndrome.

Most patients with extreme obesity do not exhibit alveolar hypoventilation, but an intriguing minority do. The mechanism(s) of this phenomenon remain unknown. A disorder in ventilatory control has been suggested as a major factor in the pathogenesis of the obesity-hypoventilation syndrome. Accordingly, hypoxic and hypercapnic ventilatory drives were measured in 10 patients with the typical symptoms of the syndrome: obesity, hypersomnolence, hypercapnia, hypoxemia, polycythemia and cor pulmonale. Hypoxic ventilatory drive, measured as the shape parameter A, averaged 21.9 +/- 5.35, approximately one-sixth that in normal controls, A = 126 +/- 8.6 (P less than 0.01). The ventilatory response to hypercapnia also was markedly reduced, the slope of the response averaging 0.51 +/- 0.005, or about one-third the normal value of 1.83 +/- 0.13 (P less than 0.01). This decreased responsiveness in hypoxic and hypercapnic ventilatory drive was consistent throughout the group. The depression in ventilatory drive found in the obesity-hypoventilation syndrome may be causally related to the alveolar hypoventilation manifested by these patients.

Tuberculosis and alcoholism. A partial solution through detection.

Alcoholism and tuberculosis often coexist, and patients with this combination have the most frequent failures of therapy. Several intriguing alternatives to standard outpatient chemotherapy are now available. The brief MAST interview (a shortened version of the Michigan Alcoholism Screening Test) has been demonstrated to be effective in identifying alcoholism in public health clinics for tuberculosis in New Orleans and Birmingham, Ala., with scores indicating populations of alcoholic patients of 25% and 28%, respectively. The test could be administered without interrupting the routine of the clinic. We believe that the problem of inadequate therapy in the alcoholic patient with tuberculosis is significant and widespread and is not being handled well is most places. Identification of the potential problem patient at first contact will be most helpful in choosing candidates for specialized forms of therapy, including short-term and supervised treatment, begun before failure of therapy ensues.

Standard therapy for tuberculosis 1985.

PIP: Numerous clinical trials of chemotherapy for tuberculosis conducted throughout the world over the past 4 decades have established 2 basic principles of treatment: effective treatment requires the initial concomitant administration of at least 2 drugs to which the patient's organisms are susceptible; and cure of tuberculosis requires that treatment continue beyond the time of sputum conversion and amelioration of symptoms. The treatment of tuberculosis was revolutionized in the late 1960s with the introduction of rifampin. Shorter regimens of 6-9 months in duration became possible. Scores of trials of short-course chemotherapy have been conducted, and more are planned. The goals of the new treatment regimens are to achieve effective sterilization of the tuberculous lesion in the shortest time possible. A table lists drugs now in use in the US and Canada and gives the usual doses, common side effects, and important interactions among drugs. Chemotherapeutic regimens acceptable for use in the US and Canada are well-defined combinations of drugs which must be regularly administered in the recommended dosages and rhythm for a specific time period. Regimens should be highly effective, i.e., a relapse rate of less than 5%, and have a low risk of toxic effects. Regimens also should be acceptable to patients and applicable on a community-wide basis. The regimens recommended meet these criteria and are backed by well-conducted clinical trails. A 9-month regimen consisting of isoniazid and rifampin throughout, usually supplemented in the initial phase by ethambutol, streptomycin, or pyrazinamide, is a well-tolerated regimen which will cure virtually all patients with susceptible organisms. The initial daily phase may last 2-8 weeks; the continuation phase may be administered daily or twice weekly. These regimens have an overall bacteriologic relapse rate of between zero and 4%. When 4 drugs -- isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin -- are given under close during supervision during the initial 2 months of daily or "induction" therapy, followed by an additional 4 months of isoniazid and rifampin, the results have been excellent. Where primary resistance to isoniazid or streptomycin is suspected, the patient should be placed on 1 of the following 3 regimens: isoniazid, rifampin, and ethambutol; isoniazid, rifampin, pyrazinamide, and streptomycin; or isoniazid, rifampin, pyrazinamide, and ethambutol. Short-course chemotherapy for extrapulmonary tuberculosis and chemotherapy of tuberculosis in children are reviewed along with several conditions which affect therapy -- tuberculosis during pregnancy, renal and hepatic disease, cancer and other conditions associated with immunosuppression, and drug interaction.^ieng

Prognostic significance of age and tonsillectomy in uvulopalatopharyngoplasty.

The objective of this study was to analyze the results of uvulopalatopharyngoplasty on 133 adult patients with sleep apnea. This group of patients was subjected to computer analysis by a statistician. Two previously unreported observations were revealed: There was a straight line decline in measurable improvement with advancing age so, by age 60, there were no patients with improvement; and patients who had tonsillectomy as a part of the uvulopalatopharyngoplasty had a markedly increased success rate compared to those who did not have tonsils. These two previously unreported observations might have significance and value in establishing guidelines for preoperative prognostic predictions of success.

Effects of progesterone on chemosensitivity in normal men.

Progesterone administration increase VE in man, but its effects on ventilatory response to hypercapnia and hypoxia have not been well documented. Accordingly, VE, HVR, and HCVR were measured during placebo and MPA administration in 11 normal men. The effect of MPA (20 mg orally q 8 hr for 32 hr) on T degrees, metabolic rate (VO2 and VCO2) was also determined. With MPA, T degrees, rose 0.4 degrees C +/- 0.0008 (S.E.M.) p less than 0.0001), VE increased 0.46 +/- 0.16 L/min (p less than 0.01), and VO2 and VCO2 did not change significantly. HCVR (measured under hyperoxic conditions during rebreathing) increased significantly (P less than 0.01) from 2.9 +/- 0.33 L/min/mm Hg (placebo) to 4.0 +/- 0.29 (MPA). HVR was measured as the shape parameter A, so that when A increased, HVR was augmented. During MPA, HVR increased from A = 132 +/- 19.1 to 179 +/- 20.5 (P less than 0.02). We conclude that 60 mg of MPA daily in normal men increases VE and chemosensitivity as measured by the ventilatory response to hypercapnia and hypoxia.

Progesterone for outpatient treatment of Pickwickian syndrome.

Ten patients with the Pickwickian syndrome, characterized by obesity, hypoxemia, hypercapnia, polycythemia, and cor pulmonale, underwent long-term treatment as outpatients with medroxyprogesterone acetate. Although there was no significant weight change in the group, PaO2 rose 12.6 +/- 2.7 mm Hg (SEM) from 49 +/- 2.6 mm Hg to 62 +/- 2.3 mm Hg (P less than 0.001), while PaCO2 fell 13 +/- 2.6 mm Hg from 51 +/- 1.9 mm Hg to 38 +/- 1.2 mm Hg (P less than 0.001). Hematocrit fell from 56 +/- 2.5% to 50 +/- 1.2%, a mean fall of 6% (P less than 0.01), during medroxyprogesterone acetate therapy. In the 2 patients who had cardiac catheterization before and during medroxyprogesterone acetate therapy, mean pulmonary arterial pressure fell 13 and 19 mm Hg. There were no recurrences of cor pulmonale during treatment. These effects on arterial blood gas values and clinical state were sustained during therapy. On withdrawal of medroxyprogesterone acetate during 1-month period, arterial oxygen and carbon dioxide tensions deteriorated to their previous pretreatment values. Reinstitution of medroxyprogesterone acetate caused improvement in both the oxygen and carbon dioxide tensions. We conclude that sublingual medroxyprogesterone acetate therapy is useful in the management of the Pickwickian syndrome.

Theophylline-induced seizures in adults. Correlation with serum concentrations.

Eight patients developed grand mal seizures during intravenous theophylline therapy. None had a history of neurologic disorder, and all were acutely ill with severe pulmonary or cardiovascular disease, or both. Serum theophylline concentrations obtained within 1 hour of the seizure ranged from 25 mug/ml to 70mug/ml, with a mean value (53 plus or minus 4.8 mug/ml) more than twice the upper limit of the recommended therapeutic concentration. This serum theophylline concentration was greater than the concentration found in a group of patients with less severe drug-related symptoms (35 plus or minus 1.8 mug/ml, P less than 0.01). A third group of patients without drug-related symptoms had a mean theophylline serum concentration of 19 plus or minus 2.0 mug/ml, which was less than that found in either group with toxicity symptoms (P less than 0.05). Factors predisposing to the high serum concentrations in the patients with seizures were both higher drug dosage, compared with the other groups (P less than 0.01), and hepatic dysfunction, which was more common in both groups with drug-related symptoms.