Plastic endobronchial tubes in the management of life-threatening hemoptysis.

Plastic double-lumen endobronchial tube was used to maintain the airway in a patient with massive hemoptysis and nonresectable lung cancer. This tube is superior to the previously used Carlens tube, as it can be inserted in emergency situations and does not require surgical setting. In addition, the larger internal diameter of these tubes allows better airway clearance and passage of a flexible bronchoscope. The double-lumen tube may be considered as an alternative to selective main-stem intubation.

Acquired tracheobronchomegaly resulting in severe respiratory failure.

Tracheobronchomegaly is a distinct clinical and radiologic entity characterized by marked dilatation of the trachea and bronchi. In this report we describe a Marfanoid patient who developed TBM in his adulthood with rapid deterioration, leading to hypercapnic respiratory failure. This case represents an acquired form of TBM in a patient with Marfanoid features which has not been previously described. Tracheobronchomegaly should be considered as a cause of chronic respiratory failure in a young adult and can be diagnosed easily with chest roentgenogram and CAT scan.

Noncardiogenic pulmonary edema following laser therapy of a tracheal neoplasm.

Nd-YAG laser phototherapy has been demonstrated to be effective for the treatment of airways obstruction caused by tracheal tumors. Pulmonary edema has been reported as a complication following acute relief of an upper airway obstruction. We describe a case where laser photoresection of an endotracheal malignancy resulted in acute pulmonary edema. It is important to recognize this potential cause of respiratory deterioration following successful phototherapy to obstructing lesions of the upper airways.

Continuous positive airway pressure in COPD patients in acute hypercapnic respiratory failure.

We used mask continuous positive airway pressure (CPAP) in seven patients with acute hypercapnic respiratory failure in an attempt to avoid endotracheal intubation and mechanical ventilation. Mask CPAP was started at 5 cm H2O and then increased to a maximum of 10 cm H2O depending on the clinical response. In five patients, CPAP significantly improved gas exchange; four of these patients were weaned to oxygen by face mask without needing intubation. In two patients, gas exchange deteriorated even with CPAP of 10 cm H2O. No barotrauma or adverse hemodynamic effects were associated with CPAP. We conclude that a trial of mask CPAP may be warranted before intubation of an alert, acutely hypercapnic patient with COPD.

Nasal continuous positive airway pressure in decompensated hypercapnic respiratory failure as a complication of sleep apnea.

Cardiopulmonary failure resulting from progression of obstructive sleep apnea (OSA) is treated with endotracheal intubation and mechanical ventilation. This study was conducted to determine whether the use of nasal continuous positive airway pressure (CPAP) would rapidly reverse changes in mental status and hypercapnic acidosis in such patients with decompensated hypercapnic respiratory failure resulting from OSA. Six morbidly obese patients (mean weight, 159 +/- 19 kg) were treated with nasal CPAP and supplemental oxygen. Within 24 h of this treatment, there was a significant increase in pH, from a baseline mean of 7.23 +/- 0.03 to 7.35 +/- 0.01 (p < 0.01), and the mean PaCO2 fell from 80 +/- 4 mm Hg to 64 +/- 4 mm Hg (p < 0.01). In addition, there was a dramatic improvement in mental status within 24 h of therapy with nasal CPAP. None of the patients required intubation and mechanical ventilation. There were no complications attributable to the CPAP delivered by nasal mask. We conclude that CPAP delivered by nasal mask can be safe and effective in rapidly reversing changes in mental status and hypercapnic acidosis in this group of patients with severe respiratory failure, and nasal CPAP obviates the need for endotracheal intubation and mechanical ventilation.

Pulmonary manifestations of the acquired immunodeficiency syndrome (AIDS).

Fifteen patients with AIDS were hospitalized on the pulmonary service during the period from 1981 to 1983. We were impressed with the frequency and severity of lung involvement in these patients and evaluated them with respect to their pulmonary manifestations of AIDS. The 13 men and two women had a mean age of 32 years. Ten were active intravenous drug abusers with a mean drug use of 8.1 years. All presented with profound weight loss, ten with nonproductive cough, and eight with significant dyspnea. Fourteen of 15 patients had Pneumocystis carinii pneumonia (PCP) at the time of our evaluation. Chest radiographs in these 14 patients showed no uniform pattern which was predictive of PCP. However, all 13 patients tested had a widened alveolar arterial oxygen gradient (mean: 59 mm Hg) which correlated well with the presence of PCP. The most common pulmonary finding in our AIDS patients was infection: 14 had PCP which was readily diagnosed by transbronchial lung biopsy in eight patients, and five patients were found to have disseminated Mycobacterium avium-intracellulare which often developed after "recovery" from PCP. Therapy for PCP with trimethoprim/sulfamethoxazole (TMP/SMZ) was unsuccessful in eight of ten patients; four of these eight TMP/SMZ failures responded to pentamidine. Mortality was 100 percent in patients who had AIDS for more than one year, and 70 percent in those less than one year. Despite some symptomatic responses to therapy for pulmonary infections, the mortality in AIDS seems to be unaffected by appropriate therapy for the pulmonary manifestations of this disease.

Effects of high-dose ipratropium bromide and oral aminophylline on spirometry and exercise tolerance in COPD.

Exercise tolerance in chronic obstructive pulmonary disease (COPD) patients treated with oral aminophylline may be different from those treated with high-dose inhaled ipratropium bromide. The purpose of this study was to compare the effects of therapeutic doses of oral aminophylline with high-dose ipratropium bromide on spirometry and exercise tolerance. The study was conducted on three consecutive days in a double-blind, randomized, crossover fashion. Baseline studies obtained on each study day included vital signs, simple spirometry and a symptom-limited maximal cardiopulmonary stress test, after which patients received one of the following treatments on each day: Treatment 1, inhaled ipratropium (total dose of 144 micrograms) with placebo tablets; Treatment 2, inhaled placebo with oral aminophylline (400 mg); Treatment 3, inhaled placebo and placebo tablets. Simple spirometry was repeated at 60 and 120 min after baseline. Vital signs and cardiopulmonary stress testing was repeated at 120 min. Eighteen patients were enrolled in the study, and 17 of these completed the study. There was a significant (P < 0.05) increase in both forced expiratory volume in 1 s (FEV1), from 0.75 (0.21) to 0.92 (0.3), and forced vital capacity (FVC), from 1.8 (0.79) to 2.11 (0.84), with high-dose ipratropium despite prior beta-agonist therapy. Lack of improvement in exercise capacity was noted with ipratropium despite improvement in spirometry. These results suggest that elderly patients with severe COPD may have exercise limitation that is not directly dependent on severity of airflow obstruction. Ipratropium bromide and aminophylline demonstrated no acute effects on exercise capacity.

Cardiopulmonary responses to continuous positive airway pressure in acute asthma.

The effects of nasal continuous positive airway pressure (CPAP) on expiratory flow, arterial blood gas tensions, cardiovascular status, and dyspnea were studied in 21 patients with acute asthma. Therapy consisted of the following CPAP sequence: 30 minutes at 5 cm H2O, 20 minutes at 0 cm H2O, 30 minutes at 7.5 cm H2O, and 20 minutes at 0 cm H2O. Six control patients were fitted with a CPAP mask but given no positive-pressure therapy. Significant reductions in respiratory rate occurred from a baseline of 22.0 +/- 1.0 to 19.8 +/- 3.8 breaths/min at CPAP 5 cm H2O and to 19.4 +/- 4.3 breaths/min at CPAP 7.5 cm H2O (P < .05). No significant change occurred in forced expiratory volume in 1 second (FEV1), heart rate, mean arterial blood pressure, or arterial blood gas tension with either level of CPAP. Dyspnea, as assessed by a breathlessness score, improved during CPAP therapy (P < .05). These levels of CPAP were tolerated without deleterious side effects. In comparison, the control group showed no change in heart rate, respiratory rate, or breathlessness score during the study period. These data show that application of CPAP in acute asthma reduces respiratory rate and dyspnea with no untoward effects on gas exchange, expiratory airflow, or hemodynamics.

Use of troleandomycin as a steroid-sparing agent in both asthma and chronic obstructive pulmonary disease.

Troleandomycin has been reported to be useful for reducing the steroid requirement of patients with asthma. The purpose of this study was to evaluate the usefulness of troleandomycin in treating patients with steroid-dependent asthma as well as in patients with steroid-dependent chronic obstructive pulmonary disease (COPD). Twelve patients with obstructive airway disease were studied; 6 patients had a diagnosis of asthma, and 6 patients had COPD. All had failed previous attempts to reduce their dosage of steroids. Among the patients with asthma, it was possible to taper methylprednisolone dosage from 29.3 +/- 21.8 mg to 11.1 +/- 7.4 11.1 mg (P less than .05). In the group with COPD there was also a significant decrease in steroid dosage--from 22.6 +/- 12.2 to 6.0 +/- 4.5 mg. These changes were not associated with a decline in spirometric values; nor was improvement secondary to improved theophylline levels, as demonstrated by a significant decrease in serum theophylline levels from 12.4 +/- 3.6 mg/dL baseline to 8.5 +/- 2.8 mg/dL (P less than .001) after maximal steroid tapering. We conclude that troleandomycin is effective in reducing the steroid dosage in patients with COPD or asthma.

Effects of continuous positive airway pressure in acute asthma.

We studied flow changes, airway pressures, breathing patterns and subjective sensation during tidal breathing on continuous positive airway pressure (CPAP) in 21 acutely ill asthmatic patients and 19 controls. The measurements obtained at various levels of CPAP were compared to the value at zero end-expiratory pressure. The fractional inspiratory time (TI/TTOT) was significantly reduced in both the patients and the control group (p less than 0.01). Patients noticed the best sensation of comfort at CPAP of 5.3 +/- (SD) 2.8 and the control group at 1.6 +/- 2.5. We noted a reduction in peak tidal expiratory flow and an increase in late-phase expiratory flow during tidal breathing in both groups although these changes were not statistically significant. There was improvement in sensation of comfort during low to medium levels of CPAP in acutely ill asthmatics. We conclude that low to medium levels of CPAP may be beneficial in acute asthma by assisting inspiratory muscles. As CPAP is increased, the beneficial effects of increased end-expiratory flow rate may be offset by the reduction in peak tidal expiratory flow rates.

Spinal tuberculosis revisited.

Although the incidence of tuberculosis is decreasing, spinal tuberculosis is still an important disease. Delay in diagnosis and treatment results in long-term disability. We reviewed our cases of spinal tuberculosis diagnosed between 1975 and 1982, with special reference to those features that permit early diagnosis. Among the nine cases diagnosed, roentgenographic evidence of pulmonary tuberculosis (7/9) and positive PPD test (8/8) were found to be highly suggestive diagnostic clues. Computerized tomography (CT) of the spine was a useful way of determining the extent of the disease and following response to therapy. Various modes of therapy were used, and the outcome was related to the extent of the disease and duration of symptoms before initiation of therapy. In early stages, medical therapy alone is adequate; surgical intervention is necessary in cases with neurologic features.