Chest. 1988;94(6):1123-1124. doi:10.1378/chest.94.6.1123
Chest. 1988;94(6):1124-1125. doi:10.1378/chest.94.6.1124
Chest. 1988;94(6):1127-1132. doi:10.1378/chest.94.6.1127

The bronchial venous system closely communicates with the pulmonary circulation. To assess the changes in the bronchial circulation in chronic pulmonary venous hypertension, fiberoptic bronchoscopy and right heart catheterization were performed in 31 patients with mitral stenosis. Nonpulsatile submucosal vessel dilatation, consistently seen in all patients and called the vessel dilatation score, was assessed visually by three independent bronchoscopists. The vessel dilatation score was correlated more closely with pulmonary artery wedge pressure (r = 0.687) (p less than 0.001) than to mean pulmonary artery pressure (r = 0.531) (p less than 0.01) and right atrial pressure (r = 0.178) (NS). The vessel dilatation score decreased after reduction of the left atrial load by surgery. These results suggest that the dilated vessels observed in patients with mitral stenosis are bronchial veins that are engorged secondary to increased blood flow via bronchopulmonary anastomoses.

Chest. 1988;94(6):1133-1137. doi:10.1378/chest.94.6.1133

S-100 protein immunostaining has been advocated to identify the characteristic Langerhans' cells in the histologic diagnosis of PEG. Reliable demonstration of an increased number of Langerhans' cells is essential in difficult biopsy cases, since occasional Langerhans' cells can be found in other pulmonary lesions. We examined the S-100 protein labeling pattern in three cases of PEG and in a variety of controls. Non-Langerhans' histiocytes were labeled for lysozyme antigen on the same histologic sections using a combined ABC and PAP technique. This verified that the S-100 protein-negative histiocytes were indeed a separate population from the S-100 protein-positive histiocytes and did not represent Langerhans' cells which failed to label with antiserum to S-100 protein. This technique confirms the usefulness of S-100 protein staining in the diagnosis of PEG and offers a means to verify the reliability of the S-100 protein labeling in questionable cases.

Chest. 1988;94(6):1138-1141. doi:10.1378/chest.94.6.1138

Coronary bypass patients less than 40 years of age were identified and compared with a control group previously studied at our hospital. In patients less than 40 years, the average age was 35 years. Men comprised 90.1 percent of group 1, and 83.4 percent of group 2. Operative mortality was 2.89 percent for group 1 and 2.1 percent for group 2. Patients less than 40 years were more likely to have positive family history (46.3 percent vs 21.94 percent), elevated cholesterol levels (25.62 vs 11.36 percent), and be smokers (59.09 vs 39.9 percent). Group 1 patients were less likely to have diabetes (4.54 vs 13.37 percent) or hypertension (18.18 vs 31.43 percent). The percentage of late deaths was much higher for younger patients. Postoperative angina and the need for reoperation was higher in group 1.

Chest. 1988;94(6):1142-1147. doi:10.1378/chest.94.6.1142

The efficacy of a nasopharyngeal tube was evaluated in 44 patients with obstructive sleep apnea syndrome. Twenty-four of these patients underwent repeated polysomnographic studies with the nasopharyngeal tube in place. They had a 62.3 percent decrease in apnea index and a 39.2 percent decrease in disordered breathing events/h. The nasopharyngeal tube was successful in 16 of the 24 patients (66.7 percent efficacy), and overall patient tolerance of the tube was 44.2 percent. The nasopharyngeal tube failures had a higher apnea + hypopnea index, lower SaO2 nadir, and a higher PaCO2 than the nasopharyngeal tube successes. They were also heavier than the successful patients. The nasopharyngeal tube is a useful alternative treatment for patients with OSA syndrome and may be used as an immediate therapeutic modality while the patient loses weight or as an alternative for those patients who fail or cannot tolerate nasal continuous positive airway pressure.

Chest. 1988;94(6):1148-1155. doi:10.1378/chest.94.6.1148

Total body oxygen uptake (VO2) increases during the transition from machine-assisted ventilation to spontaneous breathing. Since the volume of oxygen consumed by the respiratory muscles must contribute to the increase in VO2 (delta VO2), we explored whether delta VO2 and/or measurements of respiratory power output (Wresp) provide clinically useful information in the evaluation of disease state and weaning decisions in patients with respiratory failure. We determined the metabolic, ventilatory, and hemodynamic responses of ten patients during weaning from controlled mechanical ventilation, and compared delta VO2 and Wresp of patients without overt heart-lung disease (group 1) to that of patients with significant cardiopulmonary dysfunction and ventilator-dependent respiratory failure (group 2). We reasoned that for delta VO2 to be clinically useful, individual values must either clearly differ between groups, must be higher in patients with heart-lung disease, and/or correlate with weaning outcome and independent measurements of respiratory work. The VO2 increased in nine of ten patients. The differences between the groups in the values of delta VO2 (27 ml/min and 49 ml/min) and respiratory power (9.38 J/min and 11.99 J/min) were not significant. delta VO2 and Wresp were not correlated (r = 0.2), and neither predicted weaning outcome. We conclude that the sensitivity and specificity of delta VO2 and Wresp appear insufficient for evaluation of disease state and weaning decisions in individual patients.

Chest. 1988;94(6):1156-1160. doi:10.1378/chest.94.6.1156

Objective evidence of improvement from participation in an outpatient pulmonary rehabilitation program in a community hospital is shown. Selection criteria included a decrease in functional capacity due to pulmonary disease, stability of underlying pulmonary disease, proper motivation, the absence of other significant diseases, and evidence of continued improvement in the course of the program. Objective evidence of improved functional ability, as measured by treadmill exercise testing and improved understanding of their disease, was demonstrated in 86 percent of patients who completed the program. An increased work load was performed at a lower heart rate and respiratory rate. Eleven of 41 patients reached anaerobic threshold at a higher work load. Most importantly, however, was improved quality of life. In follow-up of 101 patients from one to five years later, 31.7 percent remained improved, while 31.7 percent had died, and 36.5 percent were worse from progression of pulmonary or occurrence of other diseases. Outpatient pulmonary rehabilitation can be objectively shown to be an important therapeutic tool in the treatment of patients with pulmonary disease.

Chest. 1988;94(6):1161-1168. doi:10.1378/chest.94.6.1161

Previous reports of pulmonary rehabilitation programs have demonstrated improvement in exercise capacity in subjects with disabling pulmonary disease. However, the cost-effectiveness, benefits to outpatients in a community setting, durability of these improvements, and mechanism of improved exercise capacity remain unclear. Forty-four patients with an average FEV1 of 33 +/- 4 percent of predicted completed a six-week long period of supervised treadmill exercise, as well as a continuing home program. Twenty percent had previously unsuspected cardiac disease discovered through the program, while 36 percent had previously unsuspected exercise desaturation. Cardiopulmonary stress testing before and after the program revealed a 73 +/- 16 percent improvement in aerobic capacity (METs peak [power]) and a 250 +/- 78 percent improvement in endurance (MET-min [work]). No significant change was seen in VE max, HR max, FEV1, or the degree of exercise desaturation. Only a small improvement was noted in VO2 max (15 +/- 8 percent) and O2 pulse (16 +/- 8 percent), suggesting that most of the improvement was due to improved muscle efficiency. Follow-up testing at 12 +/- 3 months in 24 subjects revealed that 89 +/- 7 percent of the peak exercise performance was maintained. The cost of the basic program was +800. The results demonstrated that an outpatient community hospital pulmonary rehabilitation program can accomplish substantial exercise capacity improvement with sustained benefits in a cost-effective manner.

Chest. 1988;94(6):1169-1175. doi:10.1378/chest.94.6.1169

In 100 patients with chronic obstructive pulmonary disease (COPD), we found no significant correlation between simultaneous measurements of right ventricular ejection fraction, using radionuclide ventriculography, and pulmonary arterial pressure. There was, however, a weak but significant correlation between right ventricular ejection fraction and the pulmonary vascular resistance (r = 0.40, p less than 0.005). In 52 of these patients, 37 with pulmonary hypertension, right ventricular end-systolic volume index was 53 +/- 21 ml.m-2 and end-diastolic volume index was 86 +/- 27 ml.m-2, compared with a calculated mean of 33 ml.m-2 and 79 ml.m-2, respectively, for normal subjects. In 24 of these patients where the measurements were made at rest and on exercise, the mean right ventricular end-systolic volume increased from 66 +/- 20 ml.m-2 to 87 +/- 32 ml.m-2, with an increase in right ventricular systolic pressure from 28 +/- 9 mm Hg to 55 +/- 15 mm Hg. Analysis of the slope of the right ventricular end-systolic pressure volume relationship at rest and on exercise suggested relatively normal right ventricular contractility in the majority of patients. Thus, in these patients with stable COPD, despite the presence of pulmonary hypertension, right ventricular contractility remained relatively normal.

Chest. 1988;94(6):1176-1186. doi:10.1378/chest.94.6.1176

Survivors of high-risk surgical operations were previously observed to have significantly higher mean CI, DO2, and VO2 than nonsurvivors. The hypothesis was proposed that increased CI and DO2 are circulatory compensations for increased postoperative metabolism. We tested this hypothesis in two series. In series 1, prospectively allocated by services, mortality and morbidity of the control group were significantly greater than those of the protocol group. In series 2, patients who fulfilled previously defined high-risk criteria were preoperatively randomized to one of three monitoring/treatment groups: CVP-control group, PA-control group and PA-protocol group. Postoperative mortalities in the CVP-control and PA-control groups were not statistically significantly different, but PA-protocol group mortality was significantly reduced compared with its control group. The PA-protocol group had reduced complications, duration of hospitalization, duration in ICU, and mechanical ventilation, and reduced costs when the PA catheter was placed preoperatively and used to augment circulatory responses.

Chest. 1988;94(6):1187-1194. doi:10.1378/chest.94.6.1187

A stratified random sample of a large state (Michigan) was studied by respiratory questionnaire, medical history, and physical examination. Data were obtained on 1,169 white adults. The prevalence of chronic bronchitis and chronic wheezing varied with sex (greater in men) and smoking history (greatest in current smokers). The prevalence of chronic bronchitis varied depending on whether it was (1) defined simply as chronic production of sputum, (2) diagnosed by the examining physician, or (3) previously diagnosed by a physician. Dyspnea was more common in women; in men, it was least common in nonsmokers but was of similar prevalence in ex-smokers and current smokers. Angina was more commonly reported by women, but previously diagnosed heart attack was consistently more common in men. Wheezing was by far the most common physical sign, present in 5.1 percent of the total population and 9.2 percent of male current smokers. Clubbing and rales were each noted in 1.2 percent of the total population. The prevalences of clinical findings in this cross section of a large state should be useful for comparison with other populations.

Chest. 1988;94(6):1195-1199. doi:10.1378/chest.94.6.1195

In a previous study we induced digital vasospasm with cold pressor stimulus, and an acute decrease in the lung diffusing capacity for carbon monoxide (Dsb) resulted. We hypothesized its cause to be spasm occurring simultaneously in the pulmonary vasculature and the digital arteries. We measured in this study the Dsb, the diffusing capacity of the pulmonary membrane (Dm), and the volume of blood in the pulmonary capillaries (Vc) after cold-induced digital vasospasm in patients with Raynaud's phenomenon. Control subjects showed no significant decrease in Dsb, Dm, or Vc after cold exposure. Eight of 12 subjects with Raynaud's phenomenon had a significant decrease in Dsb 60 min after testing (25.3 +/- 6.6 vs 19.8 +/- 6.1 ml/min/mm Hg, p less than 0.01). The acute decrease in Dsb was due to a significant decrease in Vc (54 +/- 20 vs 39 +/- 10 ml, p less than 0.05), while Dm was unchanged (52 +/- 17 vs 51 +/- 20 ml/min). Four subjects who had a decrease in Dsb after cold challenge had repeated studies later after pretreatment with sublingual nifedipine. The magnitude of change in Dsb was similar to that observed in the untreated state (23.6 +/- 10.6 vs 20.9 +/- 9.6 ml/min/mm Hg). We conclude that digital vasospasm is accompanied by an acute reduction in Vc in both primary and secondary Raynaud's phenomenon and indicates concurrent vasoconstriction within the pulmonary vaculature.

Chest. 1988;94(6):1200-1204. doi:10.1378/chest.94.6.1200

As the actual mortality and morbidity of obstructive sleep apnea syndrome (OSAS) have been unknown heretofore, we undertook a follow-up study of 198 OSAS patients seen at the Stanford Sleep Disorders Clinic between 1972 and 1980, for whom either tracheostomy (71 patients) or weight loss (127 patients) had been recommended. At five-year follow-up, all of the deaths (14) had occurred among those conservatively treated with weight-loss (a mortality rate of 11 per 100 patients per five years). These patents also had a higher five-year crude vascular mortality rate: 6.3 per 100 patients per five years, with an age-standardized vascular mortality rate of 5.9 per 100 patients per five years (95 percent confidence interval [CI] 2.5-11.6) vs 0 per 100 for the surgically treated population; this despite a lower mean apnea index (43 versus 69) and a lower mean body mass index (31 versus 34 kg/m2) in the conservatively treated group. With the fictional adjunction of one possible death at five-year follow-up in the surgically treated group, the age-adjusted odds of vascular mortality at five years for the conservatively treated group was 4.7. Our data therefore encourage "aggressive" treatment for patients with OSAS.

Chest. 1988;94(6):1205-1210. doi:10.1378/chest.94.6.1205

The present study was undertaken to determine if beta-agonists delivered by nebulizer provide better clinical responses than MDI therapy in status asthmaticus. We divided 28 hospitalized asthmatic patients into three groups. Group 1 received albuterol by MDI with InspirEase. Group 2 received nebulized albuterol. Group 3 received nebulized metaproterenol. Both nebulizer regimens resulted in significant improvements in both FVC and FEV1 by 30 min after initial hospital beta-agonist treatment. No significant improvement was noted in initial spirometry in the MDI with InspirEase group. In spite of the superiority of nebulizer therapy in the initial phase of hospitalization, the daily rates of spirometric improvement and duration of hospitalization were not significantly different among the three groups. Our results indicate that nebulizer therapy provides superior spirometric improvement in the initial phase of status asthmaticus. However, both MDI and nebulizer regimens provided similar rates of spirometric improvement and duration of hospitalization.

Chest. 1988;94(6):1211-1215. doi:10.1378/chest.94.6.1211

Bronchorrhea, defined as watery sputum of 100 ml or more per day, was seen in 18 of 207 patients (8.7 percent) with bronchial asthma during attack. Fifteen bronchorrhea sputum samples were chemically examined using ten parameters: dry weight, albumin, IgA, pH, Na+, Cl-, K+, prostaglandins E and F and histamine, and compared with eight saliva samples and 17 mucoid sputum samples. Bronchorrhea sputum differed from saliva in its chemical parameters. Bronchorrhea sputum exhibited parameter values intermediate between those of saliva and mucoid sputum, except for the two following parameters. The pH of bronchorrhea sputum was significantly lower than that of mucoid sputum and histamine concentration, expressed as weight per dry weight of sample, was significantly higher in bronchorrhea than in mucoid sputum. Administration of corticosteroid or an histamine H1-blocker to five to nine asthmatic patients with associated bronchorrhea sputum during asthmatic attacks, significantly reduced the volume of bronchorrhea sputum, whereas anticholinergics and H2-blocker did not alter the sputum volume.

Topics: asthma , sputum , bronchorrhea
Chest. 1988;94(6):1216-1220. doi:10.1378/chest.94.6.1216

Using a highly sensitive monoclonal antibody kit for CK-MB, significant release of small amounts of CK-MB isoenzyme after exercise stress test was detected 4 to 6 h after induction of ischemia. This occurred in ten out of 15 patients with ischemic heart disease (66 percent) and in only one of the 18 healthy subjects (5.6 percent) serving as a control group. In five patients with coronary artery disease in whom atrial pacing was performed with simultaneous blood sampling from coronary sinus, a drastic elevation in CK-MB isoenzyme (from 2.04 +/- 2.06 ng/L to 10.88 +/- 6.9 ng/L; p less than 0.001) was detected within 10 to 30 min after induction of acute ischemia. A small but significant increase in total CK also was detected (from 21 +/- 12 IU/L to 52 +/- 14IU/L; p less than 0.01). These preliminary observations have to be further investigated in a larger group of patients before a definitive conclusion can be reached about the clinical significance of CK-MB release during exercise.

Chest. 1988;94(6):1221-1224. doi:10.1378/chest.94.6.1221

The Federal Food and Drug Administration has a system for reporting problems with medical devices that requires manufacturers of medical devices to report medical complications or equipment malfunction that causes, or could cause, death or serious injury. In a two-year period, central venous catheters were associated with 170 complications: tissue perforation, loss of catheter integrity, (including: catheter separation, severance, break, rip, puncture, or leak), and other problems. Causes of the complications were related to device failure (12 percent), health care professionals (55 percent), patients (3 percent), or pathologic or physiologic aspects (3 percent); causes of 28 percent of the complications were indeterminable. Further analysis indicated that complications (especially tissue perforation) were primarily health professional technique-related. There were no reports of complications related to infection. Data support the need for more education in catheter application and the need to modify the system by which these data are reported to more reliably detect infection.

Chest. 1988;94(6):1225-1231. doi:10.1378/chest.94.6.1225

Surgical therapy for massive hemoptysis associated with pulmonary aspergilloma carries a high morbidity and mortality in patients with limited pulmonary reserve. Bronchial artery embolization has proven ineffective in treating and in preventing recurrent episodes of hemoptysis in this group of patients. Over a four-and-one-half year period, we have successfully treated six episodes of acute hemoptysis in four patients using a percutaneously placed catheter and intracavitary instillation of amphotericin B, N-acetylcysteine, and aminocaproic acid. Advantages of this method of treatment for patients with severely compromised pulmonary reserve include: (1) no further loss of lung function; (2) ease and rapidity of catheter insertion; (3) prompt response to treatment; (4) relatively short hospitalization; and (5) ability to repeat the procedure in the same or another cavity if necessary.

Chest. 1988;94(6):1232-1235. doi:10.1378/chest.94.6.1232

Cough capacity was evaluated in 22 patients with muscular dystrophy (MD) using subjective cough assessment, cough flow-volume curves, maximum expiratory pressures (MEP), forced vital capacity (FVC), and peak expiratory flow rates (PEFR). In ten of the 22 patients transients of peak flow were generated during cough flow-volume maneuvers, indicating dynamic compression of the airways, which is considered important in the physiology of an efficient cough. Patients who could not generate peak flow transients had significantly reduced PEFR, FVC, and MEP values. Measurement of MEP was the most sensitive predictor of flow transient production during coughing; all of the patients who exhibited transients had MEP values of above 60 cmH2O, whereas the highest value of MEP recorded in patients without transients was 45 cmH2O. Three of the 12 patients who were unable to generate flow transients were considered to have an adequate cough by subjective assessment. We concluded that the measurement of MEP is extremely useful for assessment of cough strength in patients with MD.

Chest. 1988;94(6):1236-1239. doi:10.1378/chest.94.6.1236

This report describes three cases of massive mobile right heart thrombus and reviews the available literature to better define the pathophysiology, natural history and most appropriate therapy of the syndrome. The clinical presentation of most patients has been severe cardiopulmonary dysfunction and the diagnosis has been made by echocardiographic study. The most likely source of these cardiac thrombi is the large systemic veins. The associated mortality risk is very high. Therapy has, heretofore, been individualized. Embolectomy has been most favored, with a survival rate of 80 percent. The role of thrombolytic therapy remains to be delineated. Therapy should, however, be initiated rapidly because of the precipitous nature of the mortality risk.

Chest. 1988;94(6):1240-1244. doi:10.1378/chest.94.6.1240

Although many of the pulmonary manifestations of tuberculosis in the acquired immunodeficiency syndrome (AIDS) are well known, endobronchial involvement has not been previously described. We report the clinical, roentgenographic, and bronchoscopic features of three patients with endobronchial tuberculosis and AIDS. All of the patients had nonspecific symptoms of fever and cough; however, none exhibited the classic findings of dyspnea, wheezing, or hemoptysis. Smears of sputum were nondiagnostic. The chest x-ray film revealed mediastinal adenopathy in two patients and a lower lobe consolidation in the third; all had small ipsilateral pleural effusions. Endobronchial lesions were white or pink exophytic masses obstructing the airways, mimicking bronchogenic carcinoma. Areas of "classic" primary tuberculosis were seen in two of the patients. Despite ongoing clinical and roentgenographic deterioration, all patients responded well to antituberculosis medications. Given the frequency of tuberculosis in patients with AIDS and AIDS-related complex, one should maintain a high index of suspicion for involvement of the tracheobronchial tree, so as to avoid a delay in diagnosis and resultant increased morbidity and mortality.

Chest. 1988;94(6):1245-1248. doi:10.1378/chest.94.6.1245

Left ventricular ejection fractions were determined in 38 patients with Duchenne's muscular dystrophy. No significant correlation between the severity of respiratory dysfunction or age and cardiac function was seen. We suggest that the cardiac status of each patient should be evaluated separately from his respiratory status, particularly when long-term assisted ventilation is being considered.

Chest. 1988;94(6):1249-1253. doi:10.1378/chest.94.6.1249

We present a 30-year-old man with pulmonary hypertension after pulmonary embolism. Pulmonary angiography showed multiple stenoses in the pulmonary vascular tree. We treated four of these stenoses by balloon angioplasty in three sessions. Pulmonary artery pressure was reduced from 90/25 mm Hg (mean 46) to 78/13 mm Hg (mean 35) with concomitant increase of aortic pressure from 105/60 mm Hg (mean 75) to 134/68 mm Hg (mean 90). Pulmonary perfusion scintigraphy showed increase of perfusion in the treated segments. Two procedures were followed by transient segmental pulmonary edema, but no other complications were noted. We conclude that balloon angioplasty is a promising method of lowering pulmonary artery pressure and improving pulmonary perfusion in suitable cases of pulmonary hypertension secondary to pulmonary embolism.

Chest. 1988;94(6):1254-1255. doi:10.1378/chest.94.6.1254

This study evaluates the ability of an enzyme-linked immunosorbent assay (ELISA) using adsorbed mycobacterial sonicates as antigen to differentiate between patients with tuberculosis (TB) and patients with sarcoidosis. The study group consisted of 11 patients with active sarcoidosis, seven patients with sputum-positive tuberculosis, and seven normal control subjects. Serum specimens were subjected to ELISA. Serum anti-TB IgG optical density measured at 492 nm (mean +/- SD); pulmonary TB, 0.291 +/- 0.040; normal control subjects, 0.092 +/- 0.011; and sarcoidosis, 0.064 +/- 0.033 (TB vs sarcoid, p less than 10(-6)). This ELISA is a valuable test for the differentiation between sarcoidosis and TB.

Chest. 1988;94(6):1256-1259. doi:10.1378/chest.94.6.1256

A prospective, double-blind, randomized study of the role of corticosteroids in the treatment of tuberculous pleurisy was performed in 40 patients. All patients received adequate antituberculosis chemotherapy (isoniazid, 300 mg/day; rifampin, 450 mg/day; ethambutol, 20 mg/kg/day) for more than nine months. They were randomly assigned to take prednisolone 0.75 mg/kg/day orally or placebo for the initial treatment, which was tapered gradually for the next two to three months. Twenty-one were treated with steroids and 19 were given a placebo. The two groups were identical with regard to age, sex, duration from onset of symptoms to diagnosis, and initial amount of pleural effusion. The mean duration from symptoms (fever, chest pain, dyspnea) to relief was 2.4 days in the steroid-treated group, and 9.2 days in the placebo group (p less than 0.05). Complete reabsorption of pleural effusion occurred an average of 54.5 days in the steroid-treated group and 123.2 days in the placebo group (p less than 0.01). The development of residual pleural thickening was not influenced by the administration of corticosteroids. No serious side effects were noted during the treatment in either group. We conclude that the administration of corticosteroids, in conjunction with antituberculosis chemotherapy, will resolve the clinical symptoms more quickly and hasten the absorption of pleural effusion in patients with tuberculous pleurisy.

Chest. 1988;94(6):1260-1263. doi:10.1378/chest.94.6.1260

Resting energy expenditure can be obtained either by indirect calorimetry or from prediction equations. Several prediction equations were compared to the measured value of REE in a group of COPD patients with moderate to severe disease. Then, using the same group of patients, a new equation was derived by regression analysis and was prospectively tested on patients with similar characteristics. Equations derived from normal populations (Harris-Benedict, Wilmore nomogram) were shown to underestimate REE by 300-400 Kcal. Equations that use body weight as the only variable were found to be easier to use and did not appear to sacrifice accuracy. Quebbeman Ausman body weight, Quebbeman Ausman body surface area and a regression equation derived from COPD patients (males, REE = 11.5 x wt [kg] + 952; females, REE = 14.1 x wt [kg] + 515) performed better than other currently used equations. In both stable COPD and COPD with exacerbation, the mean predicted values fell within a standard deviation (+/- 167 Kcal) of measured values.

Chest. 1988;94(6):1264-1270. doi:10.1378/chest.94.6.1264

We observed 276 HIV-infected patients to determine the frequency, degree, and clinical presentation of the lymphocytic alveolitis in different stages of HIV disease, and also to identify the lymphocyte subsets involved. In 154 patients with proved lung infections or tumors (group A), bronchoalveolar lavage fluid showed lymphocytosis in 78 percent of cases. In 122 subjects (31 AIDS and 91 HIV-infected non-AIDS patients) without evidence of lung tumor or infection (group B), lymphocytic alveolitis was seen in 72 percent of cases. In 61 of 88 (69 percent) group B lymphocytic patients, we observed respiratory symptoms or diffuse interstitial opacities; however, we also observed such alveolitis in 27 of 46 (59 percent) group B patients free of respiratory symptoms and abnormality of chest x-ray film. This alveolitis was seen not only in AIDS or ARC patients but also at earlier stages of HIV infection. T-lymphocyte analysis showed a large majority (40 to 93 percent) of CD8 positive lymphocytes in the 37 patients tested. A dual fluorescence analysis revealed, in 18 subjects, that those cells were phenotypically cytotoxic (CD8 + D44 +). These findings suggest that, regardless of HIV-infection stages and of opportunistic lung infections, a CD8-positive T-lymphocyte alveolitis may be present in HIV-infected patients and could be responsible for cough, dyspnea, interstitial pneumonitis, and abnormalities of pulmonary function tests.

Chest. 1988;94(6):1271-1275. doi:10.1378/chest.94.6.1271

The value of ultrasonography and UGAB for diagnosing chest wall tumors was investigated in 21 patients of whom 13 had metastatic and eight benign disease. Chest wall tumor showed a hypoechoic mass with tapered edges. The margin between the tumor and lung was curved and smooth in all cases. Movement of the tumor during breathing was synchronized with that of the chest wall. We believe that the ultrasonography is of value in identifying tumors that are localized to the chest wall by examination of their margin and movement with respiration, in addition to their shape. Using UGAB, we were able to diagnose correctly all eight metastatic tumors and two of four benign tumors. UGAB is a safe and simple procedure for diagnosing chest wall tumors.

Chest. 1988;94(6):1275-1276. doi:10.1378/chest.94.6.1275
Chest. 1988;94(6):1277-1282. doi:10.1378/chest.94.6.1277

In 1985, the Office of Technology Assessment (OTA) was requested by the House and Senate Aging Committees (US Congress) to study implications of life-sustaining technology and the elderly. One concern was mechanical ventilation of patients with critical illness or terminal conditions. Information was requested concerning the factors that influence treatment decisions. This report brings together opinions from medical experts in focus groups about a variety of issues raised by the OTA. The answers to those questions represent the therapeutic dilemma facing the decision-maker dealing with the elderly patient and a condition of prognostic uncertainty. Although a variety of responses is presented, some uniform trends among experts are evident. Considering the current public policy debate concerning catastrophic and long-term care of the elderly, the need is apparent to establish a clearing-house of information providing documentation, education, and networking. A documentation center would serve as a resource for public policy and program planning to serve the population that requires prolonged mechanical ventilation.

Chest. 1988;94(6):1283-1284. doi:10.1378/chest.94.6.1283
Chest. 1988;94(6):1285-1286. doi:10.1378/chest.94.6.1285
Chest. 1988;94(6):1287-1288. doi:10.1378/chest.94.6.1287
Chest. 1988;94(6):1289-1290. doi:10.1378/chest.94.6.1289

A simple technique for drainage for a giant bulla with balloon catheter using chemical irritants and fibrin glue is described. This method allows physical and functional improvement without major surgery in compromised patients with giant bullae.

Chest. 1988;94(6):1291-1292. doi:10.1378/chest.94.6.1291

Carcinogenesis is a well-known complication of radiation exposure. Ionizing radiation also leads to an increased incidence of benign tumors. A 36-year-old woman had a localized fibrous mesothelioma of the pleura and an ipsilateral breast carcinoma 23 years after receiving external radiation therapy for treatment of a chest wall keloid.

Chest. 1988;94(6):1293-1294. doi:10.1378/chest.94.6.1293

A large solitary mesothelioma was found to exhibit malignant features microscopically, but benign characteristics grossly, including a surgically curative resection. The mixed behavior of this tumor supports the evolving understanding of mesotheliomas as progeny of multipotential subserosal cells with capabilities of differentiating into several tissue types with varying degrees of anaplasia.

Topics: mesothelioma
Chest. 1988;94(6):1295-1296. doi:10.1378/chest.94.6.1295

We investigated the prevalence of hypertrophic cardiomyopathy (HC) and its association with mitral anular calcium (MAC) detected by Doppler echocardiography in 379 unselected elderly patients in a long-term health care facility. HC was present in 17 of 379 patients (4 percent). Of 17 patients with HC, ten (59 percent) had asymmetric septal hypertrophy, and seven (41 percent) had idiopathic hypertrophic subaortic stenosis with resting gradients of 20 to 110 mm Hg across the left ventricular outflow tract. The mean age of patients with HC was 85 +/- 7 years compared with 82 +/- 8 years in patients without HC (difference not significant). MAC was present in 13 of 17 patients (76 percent) with HC and in 176 of 362 (49 percent) without HC (p less than 0.025).

Chest. 1988;94(6):1296-1298. doi:10.1378/chest.94.6.1296

While receiving treatment for bladder carcinoma with intravesical BCG, a 78-year-old man developed a clinical illness and roentgenographic manifestation of miliary tuberculosis. The transbronchial lung biopsy demonstrated granulomas with giant cells. Treatment with antituberculosis therapy resulted in complete resolution of the illness. The pathogenesis of this complication was considered to be due to pulmonary infection by BCG from the bladder source and differs from previously reported cases of interstitial pulmonary infiltrates which more likely represent a hypersensitivity reaction to BCG.

Chest. 1988;94(6):1298-1300. doi:10.1378/chest.94.6.1298

A patient with symptoms of sleep apnea syndrome had signs of congestive cardiac failure. A sleep study fulfilled the criteria for sleep apnea. Features of Cheyne-Stokes respiration coexisted. Management of the cardiac failure by weight loss principally due to diuretic use eliminated the symptoms of sleep apnea.

Chest. 1988;94(6):1300-1301. doi:10.1378/chest.94.6.1300

Although Nd:YAG laser photoresection of endobronchial lung tumor can result in significant arterial oxygen desaturation, oxygen supplementation during procedures is often limited due to fear of intrabronchial combustion. We gave intermittent pulse supplemental oxygen to ten patients during 26 laser procedures performed under local anesthesia using SaO2 measured by a pulse oximeter as a guide. In four procedures (15.4 percent), severe oxygen desaturation contraindicated performing or completing laser phototherapy. In the remaining 22 procedures (84.6 percent), laser photoresection was safely and successfully performed without incident. Thus, pulse oximetry is a valuable tool and intermittent oxygen supplementation with pulse oximeter guidance an effective technique for maintaining adequate oxygenation during laser photoresection.

Chest. 1988;94(6):1301-1303. doi:10.1378/chest.94.6.1301

An asymptomatic 22-year-old man was evaluated for a persistent left lower lobe infiltrate. Barium enema and upper gastrointestinal series revealed colon and small bowel freely mobile in the left thorax. CT confirmed absence of the left hemidiaphragm. This is the first reported case of total absence of a hemidiaphragm in an adult, and extends the clinical spectrum of diaphragmatic defects where strangulation of hernia contents may occur , the asymptomatic presentation of complete absence of the hemidiaphragm with the unimpeded movement of abdominal contents suggests that no treatment is necessary.

Chest. 1988;94(6):1303-1306. doi:10.1378/chest.94.6.1303

Although pentamidine isethionate is effective in the treatment of Pneumocystis carinii pneumonia, it frequently causes serious adverse reactions. We report a case of reversible pentamidine-induced cardiotoxicity, characterized electrocardiographically by prolongation of the QT interval, T-wave inversion, and electrical alternans of the U-wave. In addition, the patient had repeated episodes of ventricular tachycardia that culminated in torsades de pointes. Our case re-emphasizes the need for close patient monitoring during pentamidine therapy.

Chest. 1988;94(6):1306-1307. doi:10.1378/chest.94.6.1306

Numerous techniques are currently employed to determine resectability of lung cancer to spare patients an unnecessary thoracotomy. Echocardiography may be used to demonstrate invasion of hilar lesions into the heart. We report a case in which echocardiography demonstrated nonresectability of a lung cancer which was confirmed via a Chamberlain procedure.

Chest. 1988;94(6):1308-1309. doi:10.1378/chest.94.6.1308

A patient with downhill azygos venous flow is reported. This reverse flow was due to an obstruction in the superior vena cava and the azygos entry due to Behçet's disease. Color flow mapping of the azygos vein, using transesophageal real-time two-dimensional Doppler echography, was used for both anatomic and hemodynamic analysis.

Chest. 1988;94(6):1309-1311. doi:10.1378/chest.94.6.1309

We report ultrastructural evidence of epithelial necrosis and alveolar collapse in a patient with usual interstitial pneumonia (UIP). These changes were focal and confined to small areas characterized histologically by aggregates of interstitial fibroblasts embedded within a myxoid stroma (fibroblastic foci). Ultrastructurally, the denuded epithelial basal lamina in these areas showed deep infoldings into the interstitium, and the luminal surfaces of the resultant clefts often were re-epithelialized. These findings suggest that the fibroblastic foci commonly seen in UIP represent sites of acute lung injury, and that alveolar collapse following epithelial necrosis is an important mechanism of lung remodeling. In addition to new insights regarding the pathogenesis of fibrosis in UIP, these observations may have important implications for assessing prognosis and selecting treatment strategies.

Chest. 1988;94(6):1314-1315. doi:10.1378/chest.94.6.1314
Chest. 1988;94(6):1318. doi:10.1378/chest.94.6.1318
Topics: amiodarone , lung , iodine
Chest. 1988;94(6):1125a. doi:10.1378/chest.94.6.1125a
Chest. 1988;94(6):1125b-1126. doi:10.1378/chest.94.6.1125b
Chest. 1988;94(6):1312a. doi:10.1378/chest.94.6.1312a
Chest. 1988;94(6):1312b-1313. doi:10.1378/chest.94.6.1312b
Chest. 1988;94(6):1315a. doi:10.1378/chest.94.6.1315a
Chest. 1988;94(6):1315b-1316. doi:10.1378/chest.94.6.1315b
Topics: geotrichosis
Chest. 1988;94(6):1316a. doi:10.1378/chest.94.6.1316a
Chest. 1988;94(6):1316b-1317. doi:10.1378/chest.94.6.1316b
Chest. 1988;94(6):1317a. doi:10.1378/chest.94.6.1317a
Chest. 1988;94(6):1317b-1318. doi:10.1378/chest.94.6.1317b

Communications to the Editor

Chest. 1988;94(6):1313. doi:10.1378/chest.94.6.1313-a
Chest. 1988;94(6):1313-1314. doi:10.1378/chest.94.6.1313-b

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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543