Spirometric diagnosis of upper airway obstruction.

We evaluated the results of routine spirometry in patients with well-documented upper airway obstruction (UAO) to determine if this readily available form of pulmonary function testing could reliably identify patients with this abnormality. Our results indicate that, although individual standard spirometric indexes could not identify these patients, ratios derived from these indexes provided excellent discrimination between patients with UAO and patients with a variety of lung diseases. A ratio of maximal voluntary ventilation to forced expiratory volume in 1 s of less than 25 was present in ten (66%) of 15 patients with UAO and only one (1%) of 100 comparison patients. A ratio of forced inspiratory flow between 25% and 75% of the vital capacity to forced expiratory flow between 25% and 75% of the vital capacity of less than 1 was found in 12 (80%) of 15 patients with UAO, but in only four (4%) of 100 comparison patients. All patients with UAO had one ratio abnormal. We conclude that spirometry remains a valuable procedure in the diagnosis of UAO.

Public screening for lung disease: experience with the NIH Lung Health Study.

The Lung Health Study is the first major initiative of the National Heart, Lung, and Blood Institute in screening for and intervention in early lung disease. The objective of the study is to identify cigarette smokers who have early disease and determine whether an intervention program of smoking cessation and bronchodilator therapy will alter the course of their disease. After an extensive screening program, 5,887 participants have been randomized to one of three groups: usual care, intervention with smoking cessation and the use of a placebo inhaler, and intervention with smoking cessation and the use of ipratropium bromide. All participants will be followed for 5 years. Preliminary data from the screening indicate that chronic obstructive pulmonary disease is more prevalent than was previously recognized, that it is widespread in women as well as men, and that it is far more common in young individuals than was thought. Approximately two-thirds of the study participants have hyperreactive airways. Preliminary data from the Lung Health Study indicate that screening for lung function can be carried out in a cost-effective manner.

Myocardial function and perfusion in the CREST syndrome variant of progressive systemic sclerosis. Exercise radionuclide evaluation and comparison with diffuse scleroderma.

Myocardial function and perfusion were evaluated in 22 patients with progressive systemic sclerosis with the CREST syndrome using exercise and radionuclide techniques, pulmonary function testing, and chest roentgenography. The results were compared with a similar study of 26 patients with progressive systemic sclerosis with diffuse scleroderma. The prevalence of thallium perfusion abnormalities was similar in the groups with CREST syndrome and diffuse scleroderma, (64 percent versus 77 percent), but the defects were significantly smaller in the CREST syndrome (p less than 0.01). Reperfusion thallium defects in the absence of extramural coronary artery disease were seen in 38 percent of patients with diffuse scleroderma. This finding was not seen in any of the patients with the CREST syndrome. In diffuse scleroderma, abnormalities of both right and left ventricular function were related to larger thallium perfusion defects. In the CREST syndrome, abnormalities of left ventricular function were minor, were seen only during exercise, and were unrelated to thallium perfusion defects. Abnormal resting right ventricular function was seen in 36 percent of the patients with the CREST syndrome and was associated with an isolated decrease in diffusing capacity of carbon monoxide. It is concluded that the cardiac manifestations of the CREST syndrome are distinct from those found in diffuse scleroderma. Unlike diffuse scleroderma, abnormalities of left ventricular function in the CREST syndrome are minor and are unrelated to abnormalities of coronary perfusion. Right ventricular dysfunction in the CREST syndrome appears to be primarily related to pulmonary vascular disease.

The electrocardiogram in systemic sclerosis (scleroderma). Study of 102 consecutive cases with functional correlations and review of the literature.

The electrocardiographic findings in 102 consecutive patients with scleroderma were reviewed to determine the frequency and nature of the electrocardiographic abnormalities associated with this disease. Septal infarction pattern unassociated with QRS prolongation was present in 10 percent, compared with none of 96 control subjects (p less than 0.001). Ventricular conduction abnormalities were present in 17 percent. A normal electrocardiogram was obtained in 49 percent. A subset of 48 patients underwent detailed cardiopulmonary evaluation including exercise thallium scintigraphy, rest and exercise radionuclide ventriculography, pulmonary function tests, and chest roentgenography. Functional correlations of the electrocardiographic findings were examined in this subset. Septal infarction pattern (five of 48) and ventricular conduction abnormalities (10 of 48) were both associated with septal or anteroseptal thallium perfusion abnormalities (10 of 15 versus six of 33 of the remainder, p less than 0.005), which were present despite normal coronary angiographic results. Thallium defect scores were greater in patients with septal infarction pattern or ventricular conduction abnormalities compared with the remainder (defect scores 3.0 +/- 2.6 versus 1.4 +/- 2.2, respectively, p less than 0.025). In patients with ventricular conduction abnormalities, both left bundle branch block and right bundle branch block with left anterior fascicular block were associated with abnormal left ventricular function, whereas isolated right bundle branch block or left anterior fascicular block was associated with normal left ventricular function. A normal electrocardiographic finding (19 of 48) was associated with normal left ventricular function at rest (19 of 19). However, 11 of 19 (58 percent) had thallium perfusion defects and four of 19 (21 percent) had an abnormal response to exercise, although in none was the peak ejection fraction less than 50 percent. It is concluded that both septal infarction pattern and ventricular conduction abnormalities are electrocardiographic abnormalities associated with scleroderma heart disease; they appear to be a result of myocardial fibrosis. Some degree of myocardial fibrosis may be present with a normal electrocardiographic result, but significant left ventricular dysfunction is unlikely. Septal infarction pattern and ventricular conduction abnormalities, when present, are indicators of more advanced fibrosis.

Giant-cell interstitial pneumonia and hard-metal pneumoconiosis. A clinicopathologic study of four cases and review of the literature.

We report four cases of giant-cell interstitial pneumonia that occurred in association with exposure to hard metals. All patients presented with chronic interstitial lung disease and had open-lung biopsies that revealed marked interstitial fibrosis, cellular interstitial infiltrates, and prominent intraalveolar macrophages as well as giant cells displaying cellular cannibalism. We also review the literature to determine the sensitivity and specificity of giant-cell interstitial pneumonia for hard-metal pneumoconiosis. Although hard-metal pneumoconiosis may take the form of usual interstitial pneumonia, desquamative interstitial pneumonia, and giant-cell interstitial pneumonia, the finding of giant-cell interstitial pneumonia is almost pathognomonic of hard-metal disease and should provoke an investigation of occupational exposure.

Adult respiratory distress syndrome following intrapleural instillation of talc.

After intrapleural instillation of talc for sclerosis of malignant pleural effusions, dyspnea occurred in three patients, progressed gradually over 72 hours, and culminated in acute respiratory failure characterized by bilateral diffuse pulmonary infiltrates with normal pulmonary artery occlusion pressures. Two patients recovered and one died. The chronological similarity of the sequence of fever, dyspnea, and respiratory failure in the absence of documented infection or other conditions that predispose to the adult respiratory distress syndrome (ARDS) suggests that intrapleural talc may have induced the syndrome in these patients through unknown mechanisms. This experience emphasizes that other agents are preferable for initial attempts to promote pleural symphysis in the palliation of recurrent malignant effusions. When talc is used in patients who are unresponsive to tetracycline, we suggest clinical monitoring for respiratory compromise for 72 hours after the procedure.

The short-term effects of smoke exposure on the pulmonary function of firefighters.

The short-term effects of smoke inhalation have been little studied. This study evaluated whether firefighters experience a significant change in spirometric values following exposure to smoke from a fire. Sixty firefighters from the city of Pittsburgh completed a questionnaire (Medical Research Council) and underwent spirometric testing following exposure to house fires. The group contained 25 current smokers, 14 ever smokers, and 21 never smokers. Firefighters reporting cough, phlegm, breathlessness, and chest illnesses were more likely to be current or ever smokers than never smokers. Mean spirometric data obtained before exposure, after a minimum of four off-duty days, showed the following: FVC, 4.50 +/- 0.60L (90 percent of predicted); FEV1, 3.65 +/- 0.56L (96 percent of predicted); FEV1/FVC, 81 +/- 8 percent (106 percent of predicted); FEF25-75%, 3.71 +/- 1.13L/s (96 percent of predicted); and PEF, 7.95 +/- 1.70L/s (87 percent of predicted). After exposure, spirometry was performed on 22 firefighters. All spirometric values decreased after exposure; however, a significant decline was only seen in two indices, the FEV1 and FEF25-75%. This decline was small (3 to 11 percent). Two firefighters experienced an exaggerated decline in spirometric values after exposure, compared to the group as a whole. Neither age, smoking history, location of firefighting, intensity of smoke exposure, or use of a self-contained breathing apparatus explained the reasons for the greater decline in these two individuals. Thus, while firefighters do experience a small decrease in pulmonary function after exposure to house fires, there appears to be a small subgroup of firefighters who develop more substantial and potentially clinically important decreases in pulmonary function after smoke exposure.

Progressive intrapartum respiratory insufficiency due to pulmonary alveolar proteinosis. Amelioration by therapeutic whole-lung bronchopulmonary lavage.

A 23-year-old woman became pregnant in the setting of long-standing severe pulmonary alveolar proteinosis. A previous twin gestation had resulted in low birth-weight infants. Progressive clinical and respiratory deterioration occurred, associated with exertional arterial oxygen desaturation. Because of the severity of her physiologic derangements and concern for the fetus, whole-lung bronchopulmonary lavage was performed twice under controlled conditions. This resulted in subjective and objective improvement, followed by successful term delivery.

Does chest physical therapy work?

Postural drainage has usually been shown to be an effective component of chest physical therapy; there is currently no data showing a beneficial effect of percussion or vibration; directed coughing may be as efficacious as postural drainage (Table 3); the forced expiration technique may increase sputum clearance with or without postural drainage (Table 4).

Chest percussion and postural drainage in patients with bronchiectasis.

Patients with chronic obstructive pulmonary disease have been treated routinely with chest physical therapy for many years in spite of a lack of scientific validation of this procedure. Only recently have the indications for chest physical therapy been clarified. It is currently believed that such therapy is especially beneficial in patients with copious secretions, and that it is less effective in patients with scanty secretions. No study has specifically evaluated the efficacy of chest physical therapy in patients with bronchiectasis. We accordingly evaluated 13 patients with stable bronchiectasis to determine the effects of chest physical therapy on pulmonary function, arterial oxygenation, and sputum production and to assess whether this therapy was associated with any significant side-effects. We found that chest physical therapy was safe and well tolerated and assisted the patients in mobilization of their sputum. However, such therapy had no immediate delayed effects on pulmonary function or oxygen saturation.

Long-term prognosis of survivors of Pneumocystis carinii pneumonia. Structural and functional correlates.

Limited data exist detailing the long-term sequelae of Pneumocystis pneumonia. Open lung biopsies were obtained in seven renal transplant recipients within 48 hours of the onset of respiratory failure. Biopsy specimens and simultaneous chest roentgenograms were graded without clinical information according to the severity of alveolar damage and pulmonary infiltrates, respectively. Evaluation of pulmonary function and exercise physiology were performed 15 to 21 months after their illness. Pulmonary function indices were normal except FRC (2.65 +/- 0.56 L or 77 +/- 16 percent of predicted) and Dsb (20.0 +/- 7.2 ml/min/mm Hg or 79 +/- 19 percent of predicted). Two patients developed arterial desaturation with exercise. Alveolar damage scores correlated with later exercise arterial desaturation (r = 0.88, p less than 0.05). Simultaneous roentgenographic scores correlated with later abnormalities of Dsb (r = 0.81, p less than 0.05). Mild residual abnormalities of pulmonary function were found in five of seven adult survivors of Pneumocystis pneumonia. These abnormalities correlated with pathologic and radiographic features of the acute illness.

Chronic Obstructive Pulmonary Disease Early Intervention Trial (Lung Health Study). Baseline characteristics of randomized participants.

The Chronic Obstructive Pulmonary Disease Early Intervention Trial, or Lung Health Study, is a multicenter randomized clinical trial sponsored by the Division of Lung Diseases of the National Heart, Lung, and Blood Institute. The hypothesis being tested is that over a 5-year period, a comprehensive intervention program can reduce both the rate of decline in pulmonary function and the rates of respiratory morbidity and mortality in middle-aged smokers with mild to moderate airflow obstruction. The primary outcome variable of the trial is the annual rate of decline of maximum postbronchodilator FEV1. Secondary outcomes are the development of respiratory and nonrespiratory morbidity and mortality. After screening 73,694 cigarette smokers, aged 35 to 60 years, 5,887 participants were randomized into three equal groups: usual care, smoking intervention with daily use of a metered-dose inhaler with ipratropium bromide, and smoking intervention with inhalation of placebo. Eligible participants had a ratio of FEV1 to forced vital capacity (FVC) of 70 percent or less, were free of known life-limiting conditions, expressed willingness to enter the intervention program if so randomized, and gave written informed consent prior to entry into the trial. Spirometry, methacholine challenge, and questionnaires were strictly standardized within and across centers. The purpose of this report is to describe the characteristics of randomized participants at the time of entry into the study. For both sexes, three measures of lung function--average cross-sectional FEV1/FVC ratio, FEV1, and FEV1 percentage of predicted normal--showed slight downward trends for each successively older 5-year age cohort. The increase in FEV1 after isoproterenol was 15 percent or more in only 2.4 percent of men and 2.8 percent of women. A positive response to methacholine (defined as a fall in FEV1 of > 20 percent from baseline at concentrations up to 25 mg/ml) occurred in 63 percent of men and 87 percent of women. The cross-sectional prevalences of cough, phlegm, wheeze on most days or nights, and shortness of breath were 49 percent, 43 percent, 32 percent, and 43 percent, respectively. Respiratory symptoms were reported by a higher proportion of participants in the younger age groups than in the older age groups. Participants who reported cough, phlegm, and/or wheeze averaged lower FEV1 percent predicted and higher probability of positive response to methacholine than participants who did not. Shortness of breath appeared to be significantly associated with lower lung function and higher reactivity in men but not in women.(ABSTRACT TRUNCATED AT 400 WORDS)

Pulmonary function in progressive systemic sclerosis. Comparison of CREST syndrome variant with diffuse scleroderma.

The pulmonary function and chest roentgenograms were evaluated in 88 patients with the CREST syndrome variant of progressive systemic sclerosis (PSS or scleroderma). Seventy-two percent of the patients had abnormal pulmonary function. An isolated decrease in diffusing capacity was the most common abnormality noted, followed by restrictive abnormalities and airway obstruction. Chest roentgenograms revealed interstitial infiltrates consistent with pulmonary fibrosis in 33 percent. When compared to a contemporaneous group of 77 patients with PSS and diffuse scleroderma, patients with the CREST syndrome had similar abnormalities on pulmonary function testing and chest roentgenogram. However, patients with the CREST syndrome had a lower mean diffusing capacity despite a higher mean vital capacity; this combination of findings suggests primary pulmonary vascular disease. Calcified granulomata were identified significantly more often in PSS-CREST patients, while superior rib notching occurred exclusively in patients with PSS and diffuse scleroderma. The CREST variant of PSS is associated with frequent roentgenographic and pulmonary function abnormalities similar to those seen in PSS with diffuse scleroderma.

Elevated pleural fluid glucose: a risk for tension hydrothorax.

We have presented a case of tension hydrothorax that developed after hyperosmolar hyperalimentation fluids were infused into the pleural space through a misplaced jugular venous line. The hyperosmolar state of the pleural fluid appears to have played a prominent role in the development of the tension hydrothorax. We believe there is a risk of tension hydrothorax in any clinical situation in which the pleural fluid glucose concentration is significantly higher than the serum concentration.

Hypercapnic ventilation during exercise: effects of exercise methods and inhalation techniques.

The effect of exercise on the ventilatory response to inhaled CO2 is uncertain because previous studies using different techniques have come to different conclusions. We undertook to resolve this problem by using multiple techniques and confining our study to a uniform level of mild exercise (VO2 = 10 ml/kg min). One group of subjects exercised on a treadmill and was tested with both rebreathing and steady-state CO2 methods. A second group exercised on a bicycle while using the rebreathing method. We found that the ventilatory response to CO2 was unchanged by mild exercise, regardless of the method used for CO2 inhalation or the technique used for exercise. These results indicate that under controlled conditions mild exercise does not produce any change in ventilatory sensitivity to CO2.