Safety and efficacy of continuous intravenous morphine for severe cancer pain.

To study the efficacy and safety of continuously administered intravenous morphine for cancer pain unrelieved by standard narcotic therapy, bolus intravenous injections of 2 to 5 mg of morphine were given every 10 minutes until pain relief was achieved. Within the next hour, continuous intravenous morphine infusion was begun with the hourly dose equal to the cumulative bolus dose. Respiratory rate, pulse, blood pressure, arterial blood gas values, mental status, and pain relief were recorded at baseline and during the study period. A reduction in arterial oxygen pressure (PaO2) and/or increase in arterial carbon dioxide pressure PaCO2 of more than 20 percent of baseline values occurred, during the first 24 hours of infusion, in a minority of patients. This did not require changes in hourly morphine dose. Despite subsequent increases in morphine dose, blood gas values tended to remain at or return toward baseline values. Severe toxicity occurred during one trial and was heralded by bradypnea and marked somnolence. Major pain relief was achieved in 11 of 15 trials. Therefore, continuous intravenous morphine is effective and safe therapy. Bradypnea associated with marked somnolence is a cause for dose reduction.

Hemoptysis as the sole presentation of thyroid carcinoma.

A 23-year-old man experienced hemoptysis in 1968, secondary to papillary carcinoma of the thyroid with metastasis to the lungs. The patient was treated initially with thyroidectomy and Iodine- 131 (131I), and subsequently with radical neck dissection. Following a period of fifteen years in which the patient was well clinically, he experienced recurrent hemoptysis. No other source of bleeding was identified, and the hemoptysis was attributed to the lung metastases of the thyroid carcinoma.

Pneumocystis carinii pneumonitis in patients with lung cancer.

Pneumocystis carinii pneumonia was histologically documented in five patients with bronchogenic carcinoma. All patients had been treated with combination antineoplastic chemotherapy. Two patients received no corticosteroids, two received no chest radiotherapy, and one received neither radiotherapy nor corticosteroids. This suggests that as more patients with lung cancer are treated with intensive chemotherapy, pulmonary infection with P carinii may become an important differential diagnostic consideration in the presence of pulmonary infiltrates.

Laser therapy in patients with primary lung cancer.

Twenty-eight therapeutic bronchoscopic procedures with laser were carried out on 20 patients with primary lung cancer. Indications for laser bronchoscopic study were nonresectable, endoscopically visible tumor in patients who had any of the following complications after chemotherapy and/or radiation therapy: increasing dyspnea, postobstructive pneumonia, atelectasis, or hemoptysis from an endoscopically visible site. Symptomatic benefit was noted by 15 of 20 patients after laser therapy. There were two procedure-related deaths. Our conclusions regarding selection of patients for laser therapy of endotracheal and endobronchial lesions are given.

Mediastinal compression due to tension hydrothorax.

We describe a patient in whom a malignant pleural effusion accumulated with sufficient pressure to cause mediastinal compression resulting in acute respiratory distress, dysphagia, and massive edema of the lower extremities. Emergency thoracocentesis produced immediate relief to respiratory symptoms and dysphagia, with gradual disappearance of the edema and a weight loss of 6.8 kg (15 lb) without adjunctive medications. It is suggested that thoracocentesis is a life-saving measure in this circumstance and should be done immediately in patients with similar initial clinical findings, as further diagnostic evaluation or other therapy directed to the mediastinum will not releive the tension and will only delay removal of the fluid.

Pneumothorax with fine-needle aspiration of thoracic lesions. Is spirometry a predictor?

To assess the value of spirometry for predicting the risk of pneumothorax (PTX) following percutaneous fine needle aspiration (FNA) of thoracic lesions, we examined retrospectively the incidence of PTX in 89 FNA and associated spirometry. Spirometry results were classified as normal, obstructed, or restrictive. Overall, the PTX rate was 20 percent. When the PTX occurrence was analyzed based on our spirometry classification, no significant difference was found between the groups. A PTX occurred in 27.8 percent of the FNA performed in patients with normal spirometry. On further analysis of specific spirometry measurements (FEV1, FVC, FEV1 percent predicted, and FEV1/FVC) and incidence of PTX, no significant correlation in PTX rates was found. These data suggest that the FNA pneumothorax is not correlated with lung function as measured by routine spirometry.

Legionella pneumonia presenting as a bulging fissure on chest roentgenogram.

We report a case of Legionella pneumonia presenting as a bulging interlobar fissure on the lateral chest roentgenogram. This microorganism should be added to the list of etiologic agents producing a bulging fissure on chest roentgenogram.

Mycobacterium szulgai pulmonary infection: the importance of knowing.

A man with a clinical and roentgenographic picture of relapsing M tuberculosis pulmonary infection was subsequently found to have M szulgai infection. This case shows the importance of species identification and susceptibility determinations.

Nine-month chemotherapy for pulmonary tuberculosis.

There is extensive favorable worldwide experience with short-course chemotherapy (SCC) for pulmonary tuberculosis. It has not yet been shown, however, that daily, unsupervised SCC would be efficacious in the United States, especially in large urban centers where compliance rates are poor and alcohol abuse is common. From January 1977 to February 1980, 75 patients began treatment using SCC combining isoniazid and rifampin for nine months, accompanied by ethambutol during the first 60 days. This report describes results achieved under "field conditions" with all medications self-administered except during the first few days of hospitalization. Forty-nine patients successfully completed this regimen. No patients failed chemotherapy during treatment and no relapses have occurred during follow-up through June 1981. There were no serious drug-related side effects. This study supports the results of similar studies conducted in other countries and provides further evidence that this regimen can be adopted more widely in this country.

Treatment of localized pulmonary phycomycosis.

A patient cured of localized pulmonary phycomycosis occurring at the site of a previous lung abscess is described and the other survivors of this unusual entity are discussed. Whole-lung computerized tomographic (CT) scanning was useful in confirming the presence of a single localized lesion and led to the choice of surgical excision. A diagnostic and therapeutic approach including whole-lung CT scanning and preoperative and postoperative systemic amphotericin B therapy is suggested pending pathologic review of the tissues for possible fungal invasion beyond the resected area. The value of surgical excision when the disease appears localized is emphasized.

Continuous intravenous infusion of morphine for severe dyspnea.

We describe eight patients who had terminal lung cancer causing severe dyspnea unrelieved by oxygen, nonnarcotic drugs, or intermittent bolus narcotics. We treated these patients with continuous intravenous infusion of morphine, beginning with bolus IV injections of 1 or 2 mg of morphine every 5 to 10 minutes until the patient reported relief. A continuous morphine infusion was then started, with the hourly dose equal to 50% of the cumulative bolus dose. Vital signs, degree of sedation, and blood gases were serially followed. Six patients achieved good dyspnea relief, one had moderate relief, and one had a poor response. Variable changes were noted in the PaO2, whereas PaCO2 steadily increased in five of seven patients, and pH decreased in six. There was little change in systolic blood pressure or pulse, and only one individual had less than 10 respirations per minute. The major side effect of treatment was sedation, treated by temporarily discontinuing morphine until the patients' mental status improved and then restarting the infusion at a 50% lower hourly morphine dose. Mean time of study was 30 hours (range 16 to 87 hours). Seven of the eight study patients died during treatment. Whether morphine therapy shortened survival is uncertain. We conclude that continuous morphine infusion is effective therapy for severe dyspnea. The treatment is ethically justified. Relief of suffering is the primary goal of therapy, and less risky treatments are unavailable.

Effects of removing oxygen from patients with chronic obstructive pulmonary disease.

To determine the acute physiologic effects of removing oxygen from patients with chronic obstructive pulmonary disease (COPD) who are receiving long-term oxygen therapy, we made serial measurements in 20 patients during and after stopping low-flow oxygen therapy. Removing oxygen caused an increase in pulmonary vascular resistance, requiring 2 to 3 h to reach a new steady state. Removing oxygen therapy increased pulmonary vascular resistance index (PVRI) by 31% during rest (8.14 +/- 0.61 versus 6.23 +/- 0.51 units, p less than 0.001) and by 29% during exercise (8.11 +/- 0.9 versus 6.31 +/- 0.7, p less than 0.001). The increase in PVRI occurred because of an increase in pulmonary arterial pressure without a change in pulmonary capillary wedge pressure or cardiac index. At rest the increase in pulmonary arterial pressure caused by stopping oxygen correlated with the decrease in arterial oxygen saturation (r = 0.70, p less than 0.01). Removing oxygen decreased stroke volume index during rest and exercise. Although removing oxygen increased pulmonary vascular resistance, it did not affect systemic arterial pressure or vascular resistance. Stopping oxygen reduced arterial and mixed venous oxygen tension and oxygen delivery during rest and exercise. In patients who had a normal PaCO2 while breathing room air, removing oxygen therapy increased their oxygen consumption; conversely, in those patients who had an elevated PaCO2 while breathing room air, stopping oxygen therapy reduced oxygen delivery and oxygen consumption.(ABSTRACT TRUNCATED AT 250 WORDS)