Comparison of the anticholinergic bronchodilator ipratropium bromide with metaproterenol in chronic obstructive pulmonary disease. A 90-day multi-center study.

The short- and long-term efficacy and safety of an inhaled quaternary ammonium anticholinergic agent, ipratropium bromide, and a beta agonist aerosol, metaproterenol, were compared in 261 nonatopic patients with chronic obstructive pulmonary disease (COPD). The study was a randomized, double-blind, 90-day, parallel-group trial. On three test days-one, 45, and 90-mean peak responses for forced expiratory volume in one second and forced vital capacity and mean area under the time-response curve were higher for ipratropium than for metaproterenol. Clinical improvement was noted in both treatment groups, especially during the first treatment month, with persistence of improvement throughout the remainder of the study. Side effects were relatively infrequent and generally mild; tremor, a complication of beta agonists, was not reported by any subject receiving ipratropium. These results support the effectiveness and safety of long-term treatment with inhaled ipratropium in COPD.

Comparison of aerosolized glycopyrrolate and metaproterenol in acute asthma.

The efficacy of nebulized glycopyrrolate compared with metaproterenol was evaluated in 46 patients with acute asthma. In a double-blinded, randomized fashion, patients received, as sole therapy, either 2 mg of glycopyrrolate or 15 mg of metaproterenol every 2 h over a 6-h study period. Of the 35 patients completing the study, analysis of variance demonstrated no difference in percentage of change in FEV1 between glycopyrrolate and metaproterenol. Two hours after the initial dose, there was a 30 percent increase in FEV1 for glycopyrrolate compared with a 25 percent increase for metaproterenol (p greater than 0.05, NS). In contrast to the comparable bronchodilator activity, the side effects profile of the two agents were markedly dissimilar. Not only were subjective complaints of tremor, palpitations, and paresthesias increased for metaproterenol, but the heart rate response was significantly elevated (p less than 0.05) compared with glycopyrrolate. Based on these data, administration of the aerosolized anticholinergic agent, glycopyrrolate, is a reasonable therapeutic alternative for acute asthma.

Diffuse pulmonary ossification detected by bone scanning with Tc-99m hydroxymethylene diphosphate.

Diffuse pulmonary ossification (DPO) is a rare pathologic finding of heterotropic bone formation within the lungs. It has been associated with mitral stenosis, chronic left ventricular failure, interstitial fibrosis, metastatic breast cancer, pulmonary amyloidosis, histoplasmosis, and chronic busulfan therapy. This patient represents a case associated with Placidyl use.

Transbronchial lung biopsy in sarcoidosis. An approach to determine the optimal number of biopsies.

In order to determine if the diagnostic yield of the transbronchial lung biopsy in sarcoidosis is dependent upon the number of biopsies, a study was designed to examine individual specimens from 6 biopsies in patients with Stage II sarcoidosis. It was found that the probability of obtaining a positive specimen per biopsy was 46%, and this percentage remained constant for each biopsy. The diagnostic yield followed a logarithmic curve, gradually increasing from 1 through 4 biopsies until about 90% of true positive diagnoses were obtained, then approaching a plateau with successive biopsies. We therefore recommend that 4 transbronchial lung biopsies are sufficient to diagnose stage II sarcoidosis in the majority of patients with diffuse lung disease.

Massive hemoptysis associated with granular cell tumor of the bronchus.

We have described a patient with massive hemoptysis who was subsequently found to have an endobronchial granular cell tumor. This rare tumor has been associated with hemoptysis in 13 previous cases, but not heretofore with massive pulmonary hemorrhage.

CT attenuation values of lung density in sarcoidosis.

Mean lung density (MLD), as determined by a chest computed tomographic sector method, was evaluated in 12 patients with sarcoidosis and diffuse interstitial lung disease. The results demonstrate that MLD in sarcoidosis was -610.9 +/- 57.3 Hounsfield units (HU), significantly different (p less than 0.001) from a control group MLD of -748.1 +/- 31.9 HU. There was also a significant inverse correlation between the forced vital capacity and total lung capacity in the sarcoidosis group. Our data suggest that a major factor determining MLD in a diffuse interstitial process such as sarcoidosis is pulmonary gas volume.

Comparison of clinical parameters, bronchoalveolar lavage, gallium-67 lung uptake, and serum angiotensin converting enzyme in assessing the activity of sarcoidosis.

A major problem in pulmonary sarcoidosis is the assessment of disease activity. We established a clinical score system composed of degree of dyspnea, chest radiographic stage, forced vital capacity, and clinical assessment of disease activity (normal = 0, maximum = 16). We evaluated this score in 50 patients with sarcoidosis along with other proposed measures of disease activity: bronchoalveolar lavage percent lymphocytes (% lymphs), Gallium-67 lung uptake measured as total lung to background ratio (TL/B ratio), and serum angiotensin converting enzyme (SACE) levels. The patients we studied had an average clinical score of 5.6 +/- 2.7 (+/- SD). Though bronchoalveolar lavage % lymphs (32 +/- 20%), TL/B ratio (192 +/- 73), and SACE (137 +/- 66) were all significantly elevated in these patients, Gallium-67 uptake was most frequently abnormal (80% of patients). However, the TL/B ratio was higher in smokers (231 +/- 91) than nonsmokers (178 +/- 64, p less than 0.05). There was no correlation between our clinical score, or any part of the clinical score, and other laboratory measures of alveolitis. Bronchoalveolar lavage % lymphs and TL/B ratio correlated weakly (n = 50, r = 0.36, p less than 0.02), while % lymphs and SACE correlated less well (n = 29, r = 0.36, p = 0.051). There was no correlation between TB/L ratio and SACE.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of therapeutic response in steroid-treated pulmonary sarcoidosis. Evaluation of clinical parameters, bronchoalveolar lavage, gallium-67 lung scanning, and serum angiotensin-converting enzyme levels.

To find a pretreatment predictor of steroid responsiveness in pulmonary sarcoidosis we studied 21 patients before and after steroid treatment by clinical evaluation, pulmonary function tests, bronchoalveolar lavage (BAL), gallium-67 lung scan, and serum angiotensin-converting enzyme (SACE) level. Although clinical score, forced vital capacity (FVC), BAL percent lymphocytes (% lymphs), quantitated gallium-67 lung uptake, and SACE levels all improved with therapy, only the pretreatment BAL % lymphs correlated with the improvement in FVC (r = 0.47, p less than 0.05). Pretreatment BAL % lymphs of greater than or equal to 35% predicted improvement in FVC of 10/11 patients, whereas among 10 patients with BAL % lymphs less than 35%, 5 patients improved and 5 deteriorated. Clinical score, pulmonary function parameters, quantitated gallium-67 lung uptake, and SACE level used alone, in combination with BAL % lymphs or in combination with each other, did not improve this predictive value. We conclude that steroid therapy improves a number of clinical and laboratory parameters in sarcoidosis, but only the pretreatment BAL % lymphs are useful in predicting therapeutic responsiveness.

Analysis of homogeneity of alveolitis in pulmonary sarcoidosis by bilateral bronchoalveolar lavage, gallium-67 lung uptake, and chest radiograph.

The use of unilateral lobar bronchoalveolar lavage (BAL) to assess disease activity in pulmonary sarcoidosis assumes that the alveolitis is homogeneous throughout the lung parenchyma. Three studies were used to evaluate this premise in 21 patients with sarcoidosis who had a broad range of abnormalities: bilateral BAL cell counts, quantitated regional gallium-67 lung uptake, and analysis of chest radiographs. Based on results of these studies, we conclude that the alveolitis in sarcoidosis is homogeneous in the majority of patients, although lavage of the lingula may give erroneous results due to the frequently increased proportion of neutrophils. The only moderate level of correlation between the BAL % lymphocytes and gallium-67 lung uptake, even when the same regions of the lung are studied, suggests that these tests may measure different aspects of disease activity.

Asbestos-related radiographic abnormalities in elevator construction workers.

Elevator construction workers are exposed to asbestos dust during construction and refurbishment work on older buildings. We screened a cohort of workers, all with greater than 20 yr of employment in the industry, with clinical examinations, chest radiography ("B" reader interpretations), and routine spirometry. Twenty of the 91 workers (22%) had evidence of pleural disease, but none of them had an interstitial process consistent with asbestosis. Of those with pleural thickening, 15 had bilateral circumscribed plaques and five had unilateral plaque formation. There were no cases of diffuse pleural thickening, benign pleural effusions, or mesothelioma identified in our cohort. The difference in the mean body mass index of those with pleural abnormalities (29.18 +/- 3.95) and those without (27.7 +/- 3.86) was not statistically significant (p = 0.135). We conclude that elevator construction workers have an increased risk for the development of asbestos-related pleural disease.

Vascular effects of cigarette smoke in isolated pig lungs.

To determine the local effects of cigarette smoke on the pulmonary vasculature, we measured pulmonary artery pressure--flow curves in isolated, blood-perfused pig lungs before and after 4 exposures to cigarette smoke. During each exposure, smoke was administered into the trachea for 3 to 4 min at a rate of 20 to 25 puffs/min and a puff volume of 35 to 50 ml with a smoking machine. During hypoxia (inspired PO2, 50 mmHg), when baseline vasomotor tone was high, cigarette smoke caused an acute transient vasodilation. During control (inspired PO2, 200 mmHg), when baseline tone was low, no significant effect was observed. In addition to this acute effect, cigarette smoke caused a depression of the pulmonary pressor response to hypoxia, which developed gradually during the course of the experiment. Indomethacin, at perfusate concentrations of 20 and 100 micrograms/ml, did not significantly alter the acute vasodilating effect of smoking, suggesting that prostaglandins synthesized by cyclooxygenase were not the mediators of this response. Indomethacin did, however, prevent the gradual depression of the pulmonary vasoconstrictor response to hypoxia.