RESUMO
Two patients with adult respiratory distress syndrome (ARDS) caused by Legionnaires' disease were treated with erythromycin lactobionate, and they survived. Sequential pulmonary function studies and chest roentgenograms were obtained in both patients. Despite previous suggestions that severe fibrosis might complicate the recovery of patients with this disease, both patients had normal lung volumes and only minimal reduction in single-breath carbon monoxide diffusing capacity ten weeks after the onset of the disease. Thus, pulmonary function after ARDS caused by Legionnaires' disease seems to be only minimally disturbed.
Assuntos
Doença dos Legionários/complicações , Pulmão/fisiopatologia , Síndrome do Desconforto Respiratório/etiologia , Adulto , Eritromicina/análogos & derivados , Eritromicina/uso terapêutico , Humanos , Doença dos Legionários/tratamento farmacológico , Medidas de Volume Pulmonar , Masculino , Pessoa de Meia-Idade , Capacidade de Difusão Pulmonar , Síndrome do Desconforto Respiratório/fisiopatologia , EspirometriaRESUMO
BACKGROUND: Magnesium sulfate has been helpful in the treatment of acute exacerbations of asthma. We hypothesized that magnesium would also be an effective bronchodilator in patients with chronic stable asthma. METHODS: We performed a prospective, randomized, double-blind, placebo-controlled, crossover trial in 15 patients with chronic, stable asthma and 10 nonasthmatics. On study day 1, spirometry and albuterol challenge were used to confirm the presence of asthma according to American Thoracic Society criteria. On study day 2, subjects received intravenous magnesium sulfate (2 g) or placebo (saline). On study day 3, subjects were crossed over to receive the other drug. Spirometry was performed before, during, and after drug or placebo administration. Circulating ionized magnesium concentrations were determined before and after intravenous magnesium or placebo administration. RESULTS: Magnesium infusion caused no statistically significant changes in forced expiratory volume in 1 second (mean +/- SEM, 1.92 +/- 0.13 L before, 1.98 +/- 0.12 L during, and 2.01 +/- 0.14 L after magnesium administration), forced vital capacity (mean +/- SEM, 3.44 +/- 0.25 L before, 3.60 +/- 0.26 L during, and 3.59 +/- 0.25 L after magnesium administration), or maximum forced expiratory flow rate (mean +/- SEM, 5.42 +/- 0.44 L/second before, 5.46 +/- 0.46 L/second during, and 5.57 +/- 0.49 L/second after magnesium administration). Placebo caused no changes in these three physiologic variables. CONCLUSION: Magnesium is not effective as a bronchodilator in chronic, stable asthmatics or in normal non-asthmatic adults.
Assuntos
Asma/tratamento farmacológico , Sulfato de Magnésio/uso terapêutico , Adulto , Asma/sangue , Asma/fisiopatologia , Doença Crônica , Método Duplo-Cego , Feminino , Humanos , Masculino , Estudos Prospectivos , Testes de Função Respiratória , Falha de TratamentoRESUMO
Six patients with refractory neurosarcoidosis were enrolled in a 12-month open-label trial to investigate the safety and efficacy of cyclosporine therapy. Patients were stabilized on a corticosteroid dose, randomized to a low-dose or high-dose cyclosporine group (with appropriate target whole blood cyclosporine levels) for 6 months, and assessed by prospectively defined studies. The corticosteroid dose was adjusted as clinically tolerated. We found that the corticosteroid dose could be lowered to 30% to 58% of the initial stabilization dose in conjunction with cyclosporine therapy, at the time of maximal clinical and laboratory improvement. However, four patients deteriorated while using corticosteroids and cyclosporine; one of these patients died. At the time of clinical deterioration, the prednisone dose ranged from 6 to 22.5 mg daily (or the equivalent). No serious toxic effects developed from cyclosporine therapy. Cyclosporine treatment is a reasonably safe and effective adjunct to corticosteroid therapy for patients with refractory neurosarcoidosis, although clinical deterioration can occur despite combination therapy.
Assuntos
Ciclosporina/uso terapêutico , Doenças do Sistema Nervoso/tratamento farmacológico , Sarcoidose/tratamento farmacológico , Adulto , Glicemia/análise , Proteínas do Líquido Cefalorraquidiano/análise , Contagem de Eritrócitos , Potenciais Evocados , Feminino , Humanos , Imunoglobulina G/líquido cefalorraquidiano , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/sangue , Doenças do Sistema Nervoso/fisiopatologia , Peptidil Dipeptidase A/sangue , Prednisona/uso terapêutico , Sarcoidose/sangue , Sarcoidose/fisiopatologia , Nervo Tibial/fisiopatologiaRESUMO
PURPOSE: Amiodarone has proven to be effective in many cases of cardiac arrhythmias, refractory ventricular tachycardia, and ventricular fibrillation. Pulmonary toxicity is a possible side effect of the drug, with a reported incidence of 2 to 15 percent per year. To determine the effect of amiodarone on lung function, we prospectively studied serial lung function tests in a cohort of 91 patients with refractory cardiac arrhythmias treated with this agent. PATIENTS AND METHODS: Spirometry and carbon monoxide diffusing capacity (DLCO) were measured at zero, three, six, 12, 18, and 24 months, with a mean follow-up of 351 days. RESULTS: For the whole population taking a mean dose of amiodarone of 367 mg daily (range: 136 to 512 mg), there was no accelerated rate of decline in spirometric indices or DLCO. Analysis of lung function changes by multivariate analysis demonstrated that an accelerated decline in DLCO values occurred in elderly patients (p less than 0.05) but not in patients with pre-existing lung disease or cigarette smokers. In four patients (4.5 percent), clinical evidence of amiodarone pulmonary toxicity developed that was associated with a fall in DLCO of greater than 20 percent. All four patients recovered after the drug was stopped. Another 15 patients, without clinical evidence of pulmonary toxicity, had a sustained decline in DLCO of greater than 20 percent. These 15 patients remained asymptomatic over the next 11 months without interruption of therapy. A greater than 20 percent fall in DLCO was a sensitive test for clinically evident amiodarone pulmonary toxicity, but had a positive predictive value of only 21 percent. CONCLUSION: An isolated fall in DLCO, in the absence of clinical evidence of toxicity, does not necessitate stopping amiodarone. An unchanged DLCO value appears to be a reliable negative predictor of pulmonary toxicity.
Assuntos
Amiodarona/efeitos adversos , Pulmão/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Monóxido de Carbono/metabolismo , Difusão , Feminino , Seguimentos , Volume Expiratório Forçado , Humanos , Pulmão/metabolismo , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Espirometria , Capacidade VitalRESUMO
Topical cardiac hypothermia has been shown to be a safe and effective means of providing protection for the ischemic myocardium during aortic cross-clamping. We report herein two cases of postoperative bilateral diaphragmatic paralysis which we believe resulted from hypothermic injury to the phrenic nerves. After open-heart surgery, both patients experienced prolonged weaning from assisted ventilation and severe orthopnea. Return of normal diaphragmatic and phrenic nerve function was demonstrated in one patient ten months after surgery. Failure to correctly interpret the respiratory failure and orthopnea led to confusion and erroneous types of therapy. Awareness of this complication should lead to improved care and postoperative management of patients.
Assuntos
Parada Cardíaca Induzida/efeitos adversos , Nervo Frênico/lesões , Paralisia Respiratória/etiologia , Adulto , Ponte de Artéria Coronária , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologiaRESUMO
Legionella pneumophila has, in recent years, emerged as a common pulmonary pathogen in the normal and immuno-compromised patient (ICP). Making a specific etiologic diagnosis of pneumonia in the latter group is a common clinical dilemma often complicated by poor specimen availability and risks of invasive procedures. Improved staining and isolation techniques for L pneumophila would suggest that early diagnosis could be possible if adequate specimens were available. This report summarizes our experience with bronchoalveolar lavage (BAL) with which we have diagnosed L pneumophila in eight immunocompromised patients, well in advance of more traditional methods. On the basis of this experience, we would advocate early BAL in the ICP as a rapid, safe, moderately sensitive and specific diagnostic test to aid in the identification of L pneumophila.
Assuntos
Brônquios/microbiologia , Doença dos Legionários/microbiologia , Alvéolos Pulmonares/microbiologia , Adulto , Antibacterianos/uso terapêutico , Feminino , Imunofluorescência , Humanos , Legionella/isolamento & purificação , Doença dos Legionários/tratamento farmacológico , Doença dos Legionários/imunologia , Masculino , Pessoa de Meia-Idade , Coloração e Rotulagem , Irrigação TerapêuticaRESUMO
A series of 181 patients with chronic persistent sarcoidosis for more than 5 years have been reviewed, with a mean follow-up period of 14 years, and 77% followed for more than 10 years. Efforts to identify more white patients meeting the criteria of such persistent disease were unsuccessful. Seventy-eight percent were black, and 69% were women. Pulmonary disease was the major manifestation in 70% and was present in 88%. The early major disease feature predicts the nature of the long-term manifestation in 94%. Ninety-four percent were treated with prednisone, with 63% for more than 5 years. Fifty-three percent required continued treatment, and of those receiving continued treatment, 91% were maintained on doses of no more than 15 mg daily and 65% on no more than 10 mg of prednisone daily. Relapses were frequent as prednisone was withdrawn, occurring at least once in 75% and several times in 51%. Low-dose prednisone treatment with 5-15 mg daily provides significant benefit. A mean treatment period of 8 years was observed (range: 10 days to 24 years). The benefits of treatment greatly exceed the infrequent complications. In Baltimore, chronic sarcoidosis with persistent disease seems to be more frequently encountered in black patients than in white patients.
Assuntos
Pneumopatias/tratamento farmacológico , Prednisona/administração & dosagem , Sarcoidose/tratamento farmacológico , Adulto , População Negra , Cloroquina/uso terapêutico , Doença Crônica , Feminino , Seguimentos , Humanos , Pneumopatias/complicações , Masculino , Pessoa de Meia-Idade , Prednisona/efeitos adversos , Recidiva , Testes de Função Respiratória , Sarcoidose/complicações , Fatores de Tempo , População BrancaAssuntos
Eosinofilia/diagnóstico , Neoplasias Cardíacas/diagnóstico , Rabdomiossarcoma/diagnóstico , Eosinofilia/complicações , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Neoplasias Cardíacas/complicações , Ventrículos do Coração , Humanos , Masculino , Pessoa de Meia-Idade , Rabdomiossarcoma/complicações , SíndromeAssuntos
Linfadenopatia Imunoblástica/diagnóstico , Pneumopatias/etiologia , Doenças Linfáticas/diagnóstico , Adulto , Infecções Bacterianas/complicações , Infecções Bacterianas/diagnóstico , Ciclofosfamida/uso terapêutico , Diagnóstico Diferencial , Feminino , Humanos , Linfadenopatia Imunoblástica/tratamento farmacológico , Doenças Linfáticas/complicações , Doenças Linfáticas/diagnóstico por imagem , Neoplasias/complicações , Neoplasias/diagnóstico , Radiografia , Sarcoidose/complicações , Sarcoidose/diagnóstico , Vincristina/uso terapêuticoAssuntos
Variação Antigênica/genética , Regulação da Expressão Gênica/genética , Pneumopatias/genética , Pulmão/imunologia , Receptores de Antígenos de Linfócitos T/genética , Sarcoidose/genética , Variação Antigênica/imunologia , Regulação da Expressão Gênica/imunologia , Humanos , Pneumopatias/imunologia , Receptores de Antígenos de Linfócitos T/imunologia , Sarcoidose/imunologiaRESUMO
We compared the effects of shallow breathing of air (LVB-air) and oxygen (LVB-O2) at low lung volumes (below closing capacity) and tidal breathing at FRC (FRC-air, FRC-O2) on the production of crackles in 5 normal volunteers. Two microphones were attached on the right posterior chest wall in the midclavicular line 10 and 20 cm from the apex of the right lung, respectively (M10 and M20), to record crackles during various breathing maneuvers. We found that after LVB-air and LVB-O2, there were changes in residual volume as measured by the body plethysmograph. Both inspiratory and expiratory limbs of the quasi-static pressure volume curve were shifted to the right. Occasionally, some subjects coughed after LVB-air and/or LVB-O2. Inspiratory crackles occurred mostly at the upper third of vital capacity (VC) after LVB-air and LVB-O2 and were confined almost exclusively to the dependent lung zones (M20). The inspiratory transpulmonary pressure at 25% (PL25) and 50% (PL50) of VC correlated with the volume of trapped gas that was absorbed (delta Vtg) (p less than 0.001 and p less than 0.001, respectively). The quantity of crackles correlated with delta Vtg (p less than 0.01). We conclude that during low lung volume breathing airways in the dependent lung regions are closed. There is absorption of trapped oxygen which causes reversible atelectasis. Upon reinflation, inspired air will go to the lung regions with open airways first and subsequently to the closed dependent regions, producing crackles recorded by the M20 microphone at the upper third of VC. The crackles are produced by inflation of atelectatic lung.
Assuntos
Pulmão/fisiologia , Sons Respiratórios/etiologia , Ar , Auscultação/instrumentação , Humanos , Oxigênio , Pletismografia Total , Ventilação Pulmonar , Volume de Ventilação Pulmonar , Capacidade VitalRESUMO
Detailed pulmonary function studies were performed on 2 patients with diffuse pulmonary North American blastomycosis before and after therapy. Our studies showed a significant increase in lung restriction, stiffness, and small airways obstruction, which completely resolved with therapy. We conclude that adequate therapy, even in the presence of extensive disease, results in both clinical and physiologic recovery.
Assuntos
Blastomicose/fisiopatologia , Pneumopatias Fúngicas/fisiopatologia , Respiração , Blastomicose/diagnóstico por imagem , Feminino , Humanos , Pulmão/diagnóstico por imagem , Pneumopatias Fúngicas/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Radiografia , Testes de Função RespiratóriaRESUMO
The clinical picture of adult cystic fibrosis is usually dominated by respiratory failure. Hepatic dysfunction occurs commonly, but symptomatic cholelithiasis is a rarely reported complication of the disease. This case of common duct obstruction emphasizes the broad spectrum of sequelae that may be expected in this newly emerging population of adults with cystic fibrosis.
Assuntos
Colelitíase/etiologia , Fibrose Cística/complicações , Adulto , Colecistectomia , Doenças do Ducto Colédoco/etiologia , Humanos , Icterícia/etiologia , MasculinoRESUMO
We used a plethysmographic technique to estimate the trapped gas volume (TGV) in seven normal subjects after breathing air or O2 normally at functional residual capacity (FRC-air, FRC-O2) and near residual volume (RV) with small breaths (LVB-air, LVB-O2). If airway closure occurs, lung units subtended by closed airways would tend to collapse as TGV is absorbed; rapidly if the gas is O2 and slowly if it is air. Both inspiratory and expiratory quasi-static and static pressure-volume curves after LVB-O2 for 180 sec demonstrated a shift to the right and increased hysteresis, reduced vital capacity (VC) and significantly increased transpulmonary pressures at 25% and 50% control VC (PL25, PL50) as compared with those of FRC-O2 controls (P less than 0.01-P less than 0.001). Three VC breaths reversed these changes which suggested that they were related to atelectasis. The absolute plethysmographic RV level decreased and was also restored after three VC breaths. We used this reproducible decrease in RV level to represent the absorbed TGV (delta TGV). The delta TGV after LVB-O2 (180 sec) was significantly greater than that after LVB-air (P less than 0.001) or FRC-O2 (P less than 0.001). There was a significant correlation between the increase of delta TGV (DTGV) and the increase of PL25 (delta PL25) (P less than 0.01). The delta TGV after FRC-O2 was 128.6 +/- 50.3 ml (1.61 +/- 0.63% of TLC) and the maximal delta TGV after LVB-O2 (180 sec) averaged 504.3 +/- 40.5 m (7.5 +/- 0.37% TLC). The significant increase in delta TGV near RV during O2 as compared to air breathing is best explained by reversible atelectasis and further supports the concept of dependent airway closure at low lung volumes.
Assuntos
Ventilação Pulmonar , Respiração , Adulto , Volume de Oclusão , Capacidade Residual Funcional , Humanos , Complacência Pulmonar , Masculino , Pessoa de Meia-Idade , Volume Residual , Capacidade VitalRESUMO
Sarcoidosis continues to be a disease defined descriptively rather than by etiology. Bronchoalveolar lavage has brought new understandings of the pulmonary inflammatory process and its pathogenesis and defects in immunoregulation. Much is known of the clinical characteristics of sarcoidosis, its diagnosis and management. Spontaneous remissions are common, but when treatment is required, the response to corticosteroids is often dramatic, although long-term treatment may be required. The appropriate use of corticosteroids is discussed fully, as are special clinical problems.
Assuntos
Sarcoidose , Diagnóstico Diferencial , Humanos , Imunossupressores/uso terapêutico , Interleucina-1/biossíntese , Macrófagos/imunologia , Sarcoidose/diagnóstico , Sarcoidose/imunologia , Sarcoidose/terapia , Linfócitos T Auxiliares-Indutores/imunologiaRESUMO
In order to ascertain the correlation between progressive and transient hypoxic ventilatory drive tests, 18 healthy subjects were tested by both methods, and the results were compared. Sudden cessation of steady-state hypoxia was done in 9 of the subjects to determine if an exaggerated central depressant effect of hypoxia might occur in some persons during progressive testing and explain a low response to progressive hypoxia. Because the progressive hypoxia test is frequently used in evaluating the effects of therapeutic interventions on ventilatory drive, the reproducibility of this test over time was also evaluated in 10 subjects. THere was a significant correlation between the results of the progressive and transient hypoxic tests when data from 17 of the 18 subjects were compared by linear regression analysis (r = 0.56, p less than 0.05). In 1 of 18 subjects, the ventilatory response to progressive hypoxia was quite low, whereas the response to transient hypoxia was high, and this can possibly be explained by an exaggerated central depressant effect of hypoxia. The progressive hypoxia test is quite reproducible (variance = 0.0092) over a 5- to 7-month period. We conclude that the use of progressive or transient hypoxic ventilatory drive tests will result in similar conclusions regarding the hypoxic ventilatory drive in most persons. In addition, the progressive hypoxia test can be reliably used to evaluate the effects of therapeutic interventions on hypoxic ventilatory drive.