Chest. 1990;97(6):1281-1282. doi:10.1378/chest.97.6.1281
Chest. 1990;97(6):1282-1283. doi:10.1378/chest.97.6.1282
Topics: cystic fibrosis
Chest. 1990;97(6):1283-1284. doi:10.1378/chest.97.6.1283
Chest. 1990;97(6):1284-1285. doi:10.1378/chest.97.6.1284
Chest. 1990;97(6):1285-1288. doi:10.1378/chest.97.6.1285
Chest. 1990;97(6):1289-1294. doi:10.1378/chest.97.6.1289

The objective of this study was to compare the response of respiratory drive to progressive hypoxia under eucapnic and hypercapnic conditions in patients with severe COPD. Twenty-five patients with severe COPD and 13 nonsmoking young men were studied. The pressure in the occluded airway measured 0.1 second after the onset of inspiration was used as an index of respiratory drive. The occlusion pressure was measured at levels of SaO2 between 97 and 85 percent while eucapnic. The PETCO2 was then increased 10 mm Hg and the study repeated. The response of respiratory drive to hypoxia as measured by the slope of the regression line relating occlusion pressure to SaO2 was weak and variable in eucapnic hypoxia, and some subjects had no demonstrable response. When mild respiratory acidosis was created by increasing the PETCO2, the response to hypoxia was much greater and occurred in all subjects studied. Respiratory acidosis resulting from acute elevation of the PaCO2 greatly potentiates the increase in respiratory drive in response to hypoxia in normal subjects and in patients with severe COPD. Increase in occlusion pressure may occur with slight degrees of hypoxia when acute hypercapnia is present. These observations suggest that patients with acute respiratory failure complicating COPD, treated with controlled oxygen administration with only partial correction of hypoxia and continued respiratory acidosis, will have high respiratory drive.

Chest. 1990;97(6):1295-1298. doi:10.1378/chest.97.6.1295

To investigate the possibility that the prohormone of atrial natriuretic factor might be secreted into the pleural fluid of patients with congestive heart failure who are known to have high concentrations of both the N-terminus and C-terminus of this prohormone circulating in their plasma, six patients with class 2 New York Heart Association classified congestive heart failure had the simultaneous measurement of plasma and pleural fluid N-terminal and C-terminal atrial natriuretic factor prohormone concentrations. The 98 amino acid (aa) N-terminus, the midportion of the N-terminus consisting of aa 31-67 of the 126 aa ANF prohormone (ie, pro ANF 31-67), and the C-terminus (aa. 99-126, ANF) were found in high concentrations in the pleural fluid of all of these patients. The concentrations of the N-terminus (ie, pro ANF 1-98), and pro ANF 31-67 in pleural fluid were nearly equal to their concentration in plasma of these patients. Their plasma levels were more than double the plasma concentrations of pro ANFs 1-98 and 31-67 in 54 persons without congestive heart failure. These preliminary findings demonstrate that all 126 amino acids of the ANF prohormone are present in pleural fluid of patients with congestive heart failure since both the 98 aa N-terminus and the C-terminus (aa 99-126) are present. Whether or not the N-terminus, which contains diuretic and natriuretic peptides, secretion into pleural fluid helps clear the fluid present in the lung in congestive heart failure could not be determined from the present investigation.

Chest. 1990;97(6):1299-1306. doi:10.1378/chest.97.6.1299

To determine the efficacy of nedocromil sodium in adult asthma patients using bronchodilators alone to control their disease, a consecutive sample of 127 patients with long-term asthma was studied for 16 weeks. The patients were maintained on sustained release theophylline preparations (SRT) and inhaled and oral beta-adrenergic bronchodilators (beta 2). One hundred sixteen patients (90 percent) completed the study; one placebo-treated patient withdrew owing to throat irritation and wheezing. Nedocromil sodium provided an additional benefit to adult patients receiving SRT and inhaled beta 2-agonists. With the exception of night-time asthma, nedocromil sodium maintained this improvement for the final 12 weeks of the study despite a reduction in concomitant bronchodilator therapy.

Chest. 1990;97(6):1307-1309. doi:10.1378/chest.97.6.1307

Surgical therapy for acute traumatic transection of the thoracic aorta is widely debated in the literature. However, little is published regarding therapy for unusual intraoperative findings, especially when the existence of multiple tears of the aortic wall would increase the operative difficulties and the associated risks. Our report concerns the presentation of three consecutive cases where multiple traumatic transections of the thoracic aorta could not be diagnosed by standard preoperative techniques. Our attention is focused on different technical options and their outcome when unusual intraoperative findings are present. We concluded that the event of unusual intraoperative findings may change the initial surgical management in favor of a more definitive procedure which usually carries a longer aortic cross-clamp time. In this instance, the availability of cardiopulmonary bypass (CPB) techniques is warranted.

Chest. 1990;97(6):1310-1316. doi:10.1378/chest.97.6.1310

Psychosocial assets of 37 adults with cystic fibrosis (CF) and 46 of their healthy peers were assessed by mailed questionnaire. Major sociodemographic variables did not differ significantly between the two groups, nor did indices of emotional social support, social network density, self-esteem, or current life satisfaction. This study revealed adults with CF to function on a par with their healthy peers in nearly all respects, a finding at odds with those from uncontrolled studies and which suggests to us that many previous conclusions about the psychosocial health of adults with CF have been unwarranted. Future psychosocial studies involving patients with CF should include control groups and inferences about the effect of these patients' physical illness on their psychosocial health should not be made in the absence of normative data.

Chest. 1990;97(6):1317-1321. doi:10.1378/chest.97.6.1317

Bedside measurement of respiratory frequency is commonly performed in a cursory manner and judged to be of little clinical importance. However, in a recent study of patients being weaned from mechanical ventilation, we found that tachypnea was quite accurate in predicting an unsuccessful weaning outcome. The present study was undertaken to examine the relationship between nonobtrusive measurements of respiratory frequency, using a calibrated inductive plethysmograph, and detailed measurements of pulmonary function in 11 adult patients with cystic fibrosis of varying severity. Respiratory frequency was increased in the patients with cystic fibrosis compared with a group of healthy control subjects, as was minute ventilation and mean inspiratory flow. Respiratory frequency was a sensitive predictor of respiratory dysfunction, being significantly (p less than 0.05) correlated with airway obstruction (r = 0.76), hyperinflation (r = 0.52), arterial oxygenation (r = -0.59), rib cage-abdominal discoordination (r = 0.54), and maximum ventilation during exercise (r = 0.66). Despite the presence of tachypnea, the patients did not display shallow breathing; indeed, tidal volume was not correlated with any of the above abnormalities. In conclusion, respiratory rate was a useful indicator of respiratory dysfunction in this group of patients with cystic fibrosis.

Chest. 1990;97(6):1322-1326. doi:10.1378/chest.97.6.1322

We studied the long-term outcome after BAE for life-threatening hemoptysis in patients with CF. Data from pulmonary function tests were available for 18 of the 25 patients followed. A case-control comparison revealed that these 18 patients died sooner than hemoptysis-free patients with CF matched for age, sex, and pulmonary function (p less than 0.02), with the excess mortality occurring within the first three months after BAE. Of all 25 patients followed, six died of cardiorespiratory failure within three months of BAE; in two of them, hemoptysis was a contributing cause of death. The 19 patients who lived more than three months after BAE had a mean survival after embolization of 3.5 years (five were still alive at the end of the study). Most patients experienced long intervals (greater than 1 year) free of major hemoptysis. Extended follow-up (mean, 35 months) revealed a higher incidence of recurrent severe bleeding than previously reported for 13 of these patients followed a mean of 11 months. Repeat BAE for severe recurrence was performed successfully in eight of nine patients, without complication.

Chest. 1990;97(6):1327-1332. doi:10.1378/chest.97.6.1327

The effect of nebulizer solution temperature and dilution air humidity on the size and solute concentration of aqueous aerosol droplets were studied. Four combinations of jet-nebulizers with air compressors or oxygen sources and one ultrasonic nebulizer were tested. The temperature to which the nebulizer solution of each system fell during generation was measured. The nebulizers were then kept at set temperatures, generated aerosols collected and either droplet size or solute concentration measured. The droplet solute concentration was found to increase. The droplet size decreased along with the droplet solute concentration increase. The ultrasonic nebulizer also was tested: its high output made the concentration of the solution in the droplets much more stable. However, the proportion of droplets depositing in the tubing and valves changed markedly with aerosol flow rate. The potential for large changes in droplet solute concentration, droplet size and output during nebulization should be considered in therapeutic and diagnostic applications of nebulized aerosols.

Topics: solute
Chest. 1990;97(6):1333-1342. doi:10.1378/chest.97.6.1333

Body surface ST integral maps were recorded in 36 coronary artery disease (CAD) patients at: rest; peak, angina-limited exercise; and, 1 and 5 min of recovery. They were compared to maps of 15 CAD patients who exercised to fatigue, without angina, and eight normal subjects. Peak exercise heart rates were similar (NS) in all groups. With exercise angina, patients with two and three vessel CAD had significantly (p less than 0.05) greater decrease in the body surface sum of ST integral values than patients with single vessel CAD. CAD patients with exercise fatigue, in the absence of angina, had decreased ST integrals similar (NS) to patients with single vessel CAD who manifested angina and the normal control subjects. There was, however, considerable overlap among individuals; some patients with single vessel CAD had as much exercise ST integral decrease as patients with three vessel CAD. All CAD patients had persistent ST integral decreases at 5 min of recovery and there was a direct correlation of the recovery and peak exercise ST changes. Exercise ST changes correlated, as well, with quantitative CAD angiographic scores, but not with thallium perfusion scores. These data suggest exercise ST integral body surface mapping allows quantitation of myocardium at ischemic risk in patients with CAD, irrespective of the presence or absence of ischemic symptoms during exercise. A major potential application of this technique is selection of CAD therapy guided by quantitative assessment of ischemic myocardial risk.

Chest. 1990;97(6):1343-1348. doi:10.1378/chest.97.6.1343

To assess the effect of posture on the distribution of nebulized pentamidine isethionate deposition in the lung, ten patients with AIDS were studied. Two nebulizer systems, System 22 Mizer (MedicAid) and Respirgard II (Marquest) were modified by adding 40 cm of corrugated tubing (volume 150 ml) to allow the patients to be studied in both the sitting and supine posture. Modification of the nebulizers caused a reduction in lung deposition in the sitting position for the System 22 Mizer but increased deposition in the Respirgard II compared with the unmodified apparatus. The ratio of upper to lower zone deposition (corrected for 133Xe distribution) was increased in the supine position for both devices (p less than 0.01). The best upper zone deposition was achieved with the unmodified System 22 Mizer in the sitting position. Respirgard II had the lowest nonpulmonary deposition and the lowest incidence of adverse effects. The supine position was associated with a redistribution of deposition to the upper zones. To attempt to reduce upper zone recurrence of Pneumocystis carinii pneumonia, the supine posture is suggested for less efficient nebulizer devices, ie, the Respirgard II, but for more efficient systems, ie, System 22 Mizer, the sitting position is probably suitable. This postulate needs to be confirmed by a clinical trial.

Chest. 1990;97(6):1349-1355. doi:10.1378/chest.97.6.1349

Bronchoalveolar lavage (BAL) was performed in 51 adult immunocompromised patients (30 acquired immunodeficiency syndrome [AIDS] and 21 non-AIDS) as part of an extensive diagnostic evaluation for diffuse pulmonary infiltrates. Because multiple episodes occurred in several patients, a total of 60 BALs were performed. A diagnosis of fungal pneumonia was eventually made in 12 patients (24 percent). The organism was identified in BALs from seven of the 12, including five of seven cases of cocciodoidomycosis, one of two cases of aspergillosis, and one of three cases of cryptococcosis. Among the AIDS patients, only one case of coccidioidomycosis was diagnosed, whereas six such diagnoses were made from the 25 BALs performed on the 21 non-AIDS patients. This suggests that coccidioidomycosis is not as frequent an infection in AIDS patients in this endemic area as has been suggested previously. Candida-like organisms were identified in 23 BALs, but in no case were they clinically pathogenic. Their presence correlated with oral candidiasis (p = 0.01). Twenty-seven of 29 episodes related to Pneumocystis carinii were identified by Papanicolaou-stained cytocentrifuged BAL preparations, all but two of which were in AIDS patients. In addition, BALs detected six episodes of bacterial pneumonia and three of five cases of radiation pneumonitis. Overall, the diagnostic sensitivity of BAL was 52 of 60 or 87 percent. While examination of induced sputum for the presence of Pneumocystis may eliminate the need for bronchoscopy in some AIDS patients, BAL remains an excellent diagnostic procedure in the immunocompromised patient without AIDS.

Chest. 1990;97(6):1356-1359. doi:10.1378/chest.97.6.1356

One hundred one subjects living in northwest Hunan Province, People's Republic of China (PRC) were tested with histolyn, (Berkeley Biological Laboratories), spherulin (Berkeley Biological Laboratories), and tubersol (PPD 5 tuberculin units, Connaught Laboratories). Age of the tested subjects ranged from 16 to 58 years; 93 subjects were 22 years old or younger. Nine subjects reacted to histolyn with 5.0 mm or more induration, two subjects reacted to spherulin, and 34 subjects reacted to tubersol. One of the spherulin reactors also reacted to both histolyn and tubersol. The feasibility and advisability of doing a large-scale survey throughout the PRC seem clearly supported by this pilot project.

Topics: taiwan
Chest. 1990;97(6):1360-1366. doi:10.1378/chest.97.6.1360

We evaluated bronchial responsiveness to inhaled albuterol (salbutamol), ipratropium bromide, methacholine, and propranolol in eight heart-lung transplant (HLT) recipients 2.3 +/- 1.5 months (mean +/- SD) (range, 1 to 4.5 months) after HLT. All patients had a restrictive ventilatory defect but none had airflow limitation (FEV1/FVC = 0.93 +/- 0.05) (range, 0.86 to 0.97). Specific airway conductance (sGaw) improved significantly with both albuterol (p less than 0.01) and ipratropium bromide (p less than 0.01) but FEV1 did not. Only one HLT patient had bronchoconstriction with propranolol, whereas all but one were hyperresponsive to methacholine. Prior inhalation of ipratropium bromide blocked the response to methacholine (p less than 0.005). Serial methacholine provocation tests performed in seven long-term survivors of HLT 24.6 +/- 16.0 months (range, 12 to 51 months) after HLT revealed no time-dependent evolution of bronchial hyperresponsiveness to methacholine. Limited maximal airway narrowing to methacholine was seen in five HLT recipients who showed a 29 +/- 4 percent (range, 23 to 35 percent) fall in FEV1 compared with two patients who did not achieve a plateau with a 47 percent and 63 percent fall in FEV1, respectively. These results further our understanding of bronchial responsiveness in the denervated transplanted lung. The findings of stable hyperresponsiveness to methacholine over a prolonged time interval, limited maximal airway narrowing to methacholine, and blockade of methacholine hyperresponsiveness by ipratropium bromide support the concept of denervation hypersensitivity of muscarinic receptors.

Chest. 1990;97(6):1367-1371. doi:10.1378/chest.97.6.1367

Immunohistochemical reactivity with OKT9 (antitransferrin receptor) monoclonal antibody was studied in 58 surgically resected adenocarcinomas of the lung. The cell surface and cytoplasm of the tumor cells were stained in 44 cases (76 percent). The expression of the transferrin receptor (TrfR) in tumor cells was compared with histopathologic prognostic factors, such as TNM factors, degree of histologic differentiation, degree of nuclear atypia, and frequency of mitotic figures. The expression of TrfR showed significant correlation with the degree of histopathologic differentiation (p less than 0.025), degree of nuclear atypia (p less than 0.025), and frequency of mitotic figures (p less than 0.001). However, there was no definite correlation with TNM factors. These results indicate that the expression of the TrfR in pulmonary adenocarcinoma corresponds to the elevated proliferative activity of the tumor cells, and that immunohistochemical reactivity with OKT9 can be used as one of the histopathologic indicators of prognosis of pulmonary adenocarcinoma.

Chest. 1990;97(6):1372-1376. doi:10.1378/chest.97.6.1372

In order to determine if human LAK cells were cytotoxic against autologous AM phi, we studied the ability of human peripheral blood MNCs, stimulated in vitro with recombinant human IL-2, to lyse AM phi in a four-hour 51Cr-release assay. These cells showed significant cytotoxicity against autologous AM phi. The AM phi which had been cultured for four days served as better targets than freshly isolated AM phi. Kinetic study showed that the lysis of AM phi was proportional to the incubation time of MNCs with IL-2 and that LAK cells against AM phi required two days of in vitro culture with IL-2 for their induction. Freshly isolated MNCs did not lyse AM phi but did lyse K562 target cells, indicating that AM phi are natural killer-resistant. The phenotypes of effector cells against AM phi were found to be CD8+ or CD16+ (or both). These studies indicate that IL-2 can generate LAK cells against autologous AM phi, and this cytolytic activity must be taken into account when IL-2 or LAK cells are used for immunomodulation in patients with cancer.

Chest. 1990;97(6):1377-1380. doi:10.1378/chest.97.6.1377

To our knowledge, the effects of humidity of inspired air on bronchial blood flow in humans are unknown. During total cardiopulmonary bypass, we measured systemic to pulmonary bronchial blood flow (Qbr[s-p]) which is the volume of blood accumulating into the left side of the heart in the absence of pulmonary and coronary flow. A cannula was introduced into the right upper pulmonary vein and advanced into the lowermost portion of the left side of the heart. From this cannula Qbr(s-p) was vented by gravity and measured. Inspired gas (10 L/min, endotracheal tube, 50 percent O2 + 50 percent N2O) relative humidity was less than 20 percent and greater than 85 percent in group A (n = 25) and in group B (n = 25), respectively. Mean (+/- SE) Qbr(s-p) was 40.7 +/- 0.06 ml/min or 1.32 +/- 0.12 ml/min (percent cardiac output) in group A and 21.7 +/- 1.8 ml/min or 0.68 +/- 0.06 ml/min in group B. These data indicate that under these conditions Qbr(s-p) is increased by dry gas lung inflation in humans.

Chest. 1990;97(6):1381-1385. doi:10.1378/chest.97.6.1381

T-lymphocytes previously sensitized by an antigen undergo blastic transformation and produce IFN tau when stimulated by the same antigen. We studied the lymphoblastic response to PPD and IFN tau production in pleural fluid and peripheral blood of 41 patients (15 with tuberculous pleural effusion, 13 with nontuberculous pleurisy and positive tuberculin skin test, and 13 with tuberculin-negative nontuberculous pleurisy). In tuberculous pleuritis, pleural lymphocyte blastic response and IFN tau production were higher than those of peripheral lymphocytes, whereas in tuberculin-positive nontuberculous patients, peripheral lymphocyte response and IFN tau production were higher than those of pleural lymphocytes. Tuberculous pleural fluid lymphocytes underwent greater blastic transformation and produced more IFN tau than pleural lymphocytes of tuberculin-positive nontuberculous patients, whereas the opposite occurred in peripheral lymphocytes. In tuberculin-negative nontuberculous patients, there was no lymphoblastic response in either the pleural fluid or peripheral blood. These results concur with the concept of immunologic compartmentalization. In tuberculous pleuritis, there would be clonal expansion of PPD-responding T-lymphocytes in the pleural compartment. This expansion of PPD-specific lymphocytes would not occur in nontuberculous pleuritis, but lymphocytes sensitized to other antigens would accumulate in the pleural compartment.

Chest. 1990;97(6):1386-1389. doi:10.1378/chest.97.6.1386

Pulmonary membrane diffusing capacity (Dm) and pulmonary capillary blood volume (Vc) measurements were carried out in 21 patients with untreated tropical eosinophilia and 21 healthy controls matched for age, sex, height, and smoking habit. The mean single breath transfer factor (Dco) and the mean membrane diffusing capacity were significantly lower (p less than 0.001) in patients with tropical eosinophilia compared with control subjects. However, the mean capillary blood volume was not significantly different (p greater than 0.2). The positive correlations between Dm and transfer factor (r = 0.825), between Dm and effective alveolar volume (VA) (r = 0.721), and between Dco and VA (r = 0.774) were also highly significant (p less than 0.001) in study patients prior to treatment. These data suggest that reduction in single breath transfer factor in untreated tropical eosinophilia may be due to a reduction in membrane diffusing capacity, which in turn may be due to a reduction in area of membrane available for diffusion, as evidenced by the significantly reduced VA (p less than 0.001) in these patients. Since pulmonary capillary blood volume was normal, the pulmonary perfusion was within normal limits. Following three weeks of treatment with diethylcarbamazine citrate, although there was a significant rise in single breath transfer factor (p less than 0.001) and membrane diffusing capacity (p less than 0.05), both Dco (p less than 0.01) and Dm (p less than 0.01) continued to be significantly lower than those of control subjects. However, pulmonary capillary blood volume did not show any change (p greater than 0.2).

Chest. 1990;97(6):1390-1392. doi:10.1378/chest.97.6.1390

The diagnosis and closure of small postresection bronchopleural fistulae can be accomplished with selective bronchography and placement of fibrin sealant through the flexible fiberoptic bronchoscope. This method of diagnosis and closure of the bronchopleural fistula avoids both general anesthesia and a thoracotomy. This technique is successful in small bronchopleural fistulae and patients with multiple postresection bronchial stumps.

Chest. 1990;97(6):1393-1400. doi:10.1378/chest.97.6.1393

Stimulation of T cells via the CD3/TCR complex is associated with the reduced expression of accessory molecules, a phenomenon called modulation. To investigate whether the modulation is implicated in the pathogenic mechanism of pulmonary disease, we determined the MFI of CD3, CD4 and CD8 on lung and blood lymphocytes in ten normal subjects and 54 patients with various pulmonary and extrapulmonary diseases. Although there were no significant differences in MFI of these accessory molecules on lung lymphocytes among the groups, MFI of CD3 on lung lymphocytes was significantly decreased compared with that on blood lymphocytes in all groups, demonstrating the modulation of CD3 on lung lymphocytes. Since it has been shown that T cells whose CD3/TCR is modulated are hyporesponsive to various mitogenic signals, our observation seems to represent another aspect of the mechanism whereby the local pulmonary milieu maintains the autoregulation of immune response.

Topics: lung , t-lymphocyte , molecule
Chest. 1990;97(6):1401-1407. doi:10.1378/chest.97.6.1401

An investigation of a platinum refinery operation consisted of an administered questionnaire, spirometry, skin prick testing with platinum salts and common aeroallergens, serum total IgE, radioallergosorbent test for platinum salts, and measurement of nonspecific airway hyperresponsiveness by cold air challenge testing. Among 136 employees examined, there were 107 current and 29 medically terminated workers; 23 (17 percent) subjects had a positive platinum salts prick skin test and 19 (14 percent) displayed a positive cold air challenge. RAST binding for platinum salts IgE antibodies showed a high level of agreement with platinum skin prick test results. A proportion (63 percent) of the population (74 current and 12 terminated workers) underwent repeat platinum skin testing one year later. Among current workers, there was conversion of the platinum skin test from negative to a positive test in five employees, with three conversions occurring in workers who showed only a positive cold air challenge test the year before. Platinum skin sensitivity, asthma symptoms, and nonspecific airway hyperresponsiveness persisted for years after termination of exposure in some medically terminated workers presumably because of a delay in removal from work of employees who became sensitized to platinum salts. It is suggested that proper surveillance for occupational asthma involves the use of several testing procedures. Prompt removal from work of individuals found to become sensitized to platinum salts is important in this industry.

Chest. 1990;97(6):1408-1411. doi:10.1378/chest.97.6.1408

The incidence of atopic diseases in 206 children with nephrotic syndrome (NS) was studied. Boys with NS had three times higher incidence of bronchial asthma than the general population. There was no difference in the girls. Both boys and girls with NS had about three times more allergic rhinitis and ten times more atopic dermatitis than the general population. In NS patients with associated allergic disease, skin test and allergen-specific IgE antibodies by radioallergosorbent test (RAST) were performed. Most of the patients with dust mites (Dermatophagoides pteronyssinus, Dermatophagoides farinae), egg white, or cow's milk protein-specific antibodies had positive skin tests. One hundred of the 206 children with NS received renal biopsies and serum IgE levels were measured. During the acute nephrotic phase the geometric mean serum IgE levels in minimal change nephrotic syndrome (MCNS), IgM mesangial nephropathy (IgMN), hepatitis B virus-associated membranous nephropathy, and treatment-responsive focal segmental glomerular sclerosis patients were all significantly elevated, in descending order of significance. These high serum IgE levels decreased in remission of NS and elevated again during relapse. The relationship between high serum IgE levels in NS patients and the incidence of allergic diseases showed that one third to one fourth of either IgMN or MCNS patients developed allergic diseases. These results suggest that NS patients had a higher allergic disease incidence. Serum IgE level may serve as one of the prognostic factors. However, an increase in the IgE level may be a reflection of body immunoregulatory imbalance that plays a direct pathogenic role in the occurrence of NS and proteinuria.

Chest. 1990;97(6):1412-1419. doi:10.1378/chest.97.6.1412

Continuous positive-pressure ventilation and PSV were compared prospectively in patients at a surgical intensive care unit. All patients suffered from mild to moderate ARI (PaO2/FIO2 of 125 to 350 mm Hg). The patients were randomly assigned to a PSV group (n = 28) or a control group with continued CPPV (n = 27). The usual hemodynamic and oxygenation variables, ITBV, and extravascular lung water (ETV) were assessed before and six hours after switching to PSV. The changes (d) of PaO2/FIO2, RI, and P(A-a)O2 were used for evaluation of the effect of PSV. Significant correlations were found between the ETV(CPPV) and dPaO2/FIO2 (r = -0.672), ETV(CPPV) and dRI (r = 0.722), and ETV(CPPV) and dP(A-a)O2 (r = 0.601), which led to the conclusion that the level of ETV determined the efficacy of PSV. In the subgroup with ETV less than 11 ml/kg (n = 15), PSV significantly improved PaO2/FIO2 (248 to 286 mm Hg), RI (1.55 to 1.22), ITBV (801 to 888 ml/m2), cardiac index (4.21 to 4.76 L/min.m2), stroke index (42.2 to 48.1 ml/m2), and oxygen delivery (735 to 833 ml/min.m2). In the subgroup with ETV greater than 11 ml/kg (n = 13), PSV caused a significant deterioration of PaO2/FIO2, RI, and intrapulmonary shunt. It is concluded that in patients with moderate ARI in whom ETV is almost normal, PSV is superior to CPPV, and the efficacy of PSV is independent of the level of oxygenation during CPPV.

Chest. 1990;97(6):1420-1425. doi:10.1378/chest.97.6.1420

Pulse oximetry is widely used in the critical care setting, but few studies have examined its usefulness in clinical decision making. One area where pulse oximetry might be useful is in the titration of fractional inspired O2 concentration (FIO2) in ventilator-dependent patients. Unfortunately, documented guidelines for this use do not exist, and in a survey of directors of intensive care units, we found that they employed a wide range of target O2 saturation (SpO2) values. Consequently, we undertook a study to determine if SpO2 could be reliably substituted for measurements of arterial O2 tension (PaO2) when adjusting FIO2 in ventilator-dependent patients. We examined a number of SpO2 target values in 54 critically ill patients aiming for a PaO2 of greater than or equal to 60 mm Hg, while minimizing the risk of O2 toxicity. In white patients, we found that a SpO2 target of 92 percent was reliable in predicting a satisfactory level of oxygenation. However, in black patients, such a SpO2 reading was commonly associated with significant hypoxemia (PaO2 as low as 49 mm Hg), and a higher SpO2 target, 95 percent, was required. In addition, inaccurate oximetry readings (ie, greater than 4 percent difference between SpO2 and direct SaO2 measurements) were more common in black (27 percent) than in white patients (11 percent, p less than 0.05). In conclusion, a SpO2 target of 92 percent was reliable when titrating supplemental O2 in white patients receiving mechanical ventilation; however, in black patients, such a SpO2 reading was commonly associated with significant hypoxemia, and a higher SpO2 target, 95 percent, was required to ensure a satisfactory level of oxygenation.

Chest. 1990;97(6):1426-1430. doi:10.1378/chest.97.6.1426

Controlling a massively leaking bronchopleural fistula (BPF) can prove difficult. In combination with acute respiratory failure (ARF), BPF results in a mortality of 81 percent. Intermittent inspiratory chest tube occlusion (IICTO) is recognized as effective in controlling even the largest BPF; however, IICTO, as previously described, is difficult to use for a variety of reasons. We report two cases of BPF in association with ARF managed with a simple new device that allows the application of IICTO with virtually any mechanical ventilator. The effectiveness of the device and associated technique in controlling BPF leaks is clearly demonstrated and may have played a role in the eventual recovery of a patient with BPF. Further study of the technique is warranted.

Chest. 1990;97(6):1431-1438. doi:10.1378/chest.97.6.1431

This article is the first in a planned series from the Section on Lung Cancer of the ACCP addressing the important and clinically relevant aspects of what is now the most common malignancy in the world, lung cancer. This initial report addresses the problem of staging of lung cancer. Staging, or identifying the anatomic extent of disease according to the AJCC TNM classification scheme, is the first clinical activity in caring for a patient with known or presumed lung cancer because the results determine appropriate types of therapy. This is, therefore, a critically important aspect of the patient's care which forms the foundation for subsequent treatment. In addition, consistent use of this system, based on appropriate clinical and pathologic staging, in stratifying patients in clinical reports is mandatory; otherwise, meaningful comparisons and conclusions are impossible.

Chest. 1990;97(6):1439-1445. doi:10.1378/chest.97.6.1439

To understand the processes regulating inflammation and fibrosis in the human lung, we characterized the effects of recombinant interleukin-1, tumor necrosis factor, and gamma interferon on fibroblast proliferation, collagen production, interleukin-1-alpha production, interleukin-1-beta production, and interleukin-6-production. These studies demonstrated the existence of complex cytokine networks by which inflammatory cells regulate fibroblast function and fibroblasts, in turn, feed back to regulate inflammatory cell function. They also demonstrated that, in this complex network, the effect of an individual cytokine varies with the state of activation of the target cell, the presence of other cytokines in the local microenvironment, and the ability of the target cell to produce bioactive autocoids such as prostaglandins. Aspects of this cytokine network are discussed and a testable hypothesis for granuloma and abscess formation is detailed.

Chest. 1990;97(6):1446-1452. doi:10.1378/chest.97.6.1446
Chest. 1990;97(6):1453-1457. doi:10.1378/chest.97.6.1453
Chest. 1990;97(6):1458-1462. doi:10.1378/chest.97.6.1458

Norepinephrine, an alpha 1,2-beta 1,2-adrenergic agonist, seems to be an alternative to epinephrine, an alpha 1,2-beta 1,2-agonist, for restoration of spontaneous circulation in VF. We therefore studied the effect of epinephrine and norepinephrine on MDO2 and MVO2 using OCCM after five minutes of cardiopulmonary arrest in 21 pigs. After OCCM of three minutes, seven animals each received placebo (controls) or epinephrine (45 micrograms/kg) or norepinephrine (45 micrograms/kg). All drugs were given blindly. At 90 seconds after epinephrine or norepinephrine, mean arterial blood pressure was significantly higher than in the control group. Prior to cardiac arrest, MBF, measured with radioactive microspheres, was 193 +/- 30 ml/min/100 g. During CPR but before drug administration, MBF was 51 +/- 23 in the control group, 71 +/- 10 in the group with epinephrine, and 74 +/- 11 ml/min/100 g in the group with norepinephrine. At 90 seconds after epinephrine, MBF increased to 126 +/- 18 and after norepinephrine to 107 +/- 30 ml/min/100 g (p less than 0.05). Compared to OCCM alone, MDO2 increased from 9.6 +/- 1.7 to 17.1 +/- 3.2 ml/min/100 g after epinephrine and from 9.4 +/- 1.8 to 13.6 +/- 4.2 ml/min/100 g after norepinephrine (p less than 0.05). There was an increase in MVO2 from 4.0 +/- 1.5 to 9.4 +/- 3.0 ml/min/100 g after epinephrine (p less than 0.05), whereas MVO2 increased only from 4.2 +/- 0.8 to 5.1 +/- 2.0 ml/min/100 g after norepinephrine. Because epinephrine led to a greater increase in MVO2 than norepinephrine, the myocardial oxygen ER remained unchanged. The oxygen requirements of the fibrillating heart seemed to be increased via beta 2-adrenergic stimulation. In both the control and epinephrine-treated groups, only three of the seven animals could be successfully resuscitated, whereas all of the animals in the group with norepinephrine survived the 15-minute period of observation. In this model, norepinephrine, in contrast to epinephrine, improves the balance between MDO2 and MVO2 and eases restoration of spontaneous circulation.

Chest. 1990;97(6):1463-1466. doi:10.1378/chest.97.6.1463
Chest. 1990;97(6):1467-1470. doi:10.1378/chest.97.6.1467

Conventional radiographic studies of the chest in the intensive care unit often fail to positively identify suspected intrathoracic pathology due to many patient- and equipment-related variables. Our experience has indicated that CT scanning of the chest improves diagnostic accuracy, precisely defines anatomic abnormalities, frequently affects treatment decisions, and has been performed safely in this fragile patient population. Examples of correctable lesions have included pneumothorax, empyema, lung abscess, mediastinal abscess and pleural effusion. Chest CT findings always occurred while the portable plane chest radiographs were nondiagnostic. CT-directed intervention often improved patient outcome.

Chest. 1990;97(6):1471-1472. doi:10.1378/chest.97.6.1471
Chest. 1990;97(6):1473-1474. doi:10.1378/chest.97.6.1473
Chest. 1990;97(6):1475-1477. doi:10.1378/chest.97.6.1475

A 65-year-old man with steroid-dependent chronic airflow obstruction presented with progressive dyspnea and weight loss. Travel history included a military tour in southeast Asia. A chest roentgenogram revealed hyperexpanded lung fields with diffusely increased interstitial markings. The Papanicolaou stain of expectorated sputum demonstrated the rhabditiform larvae of Strongyloides stercoralis. Endemic areas of infection include the southeastern United States, Puerto Rico, Central America, the Pacific basin, and central Africa. In recent immigrant groups and veterans of the Vietnam conflict, rates of infection are as high as 6 percent. The hyperinfection syndrome occurs in immunocompromised hosts and is associated with glucocorticoid steroid therapy. This allows massive proliferation of larval forms. Clinical clues include an appropriate travel history (even in the remote past), gastrointestinal symptoms, cutaneous symptoms, eosinophilia, or thrombocytosis. Our patient demonstrated a classic presentation of the hyperinfection syndrome, and the condition responded well to thiabendazole.

Chest. 1990;97(6):1478-1480. doi:10.1378/chest.97.6.1478

We report two cases of pulmonary edema due to scorpion sting. Radionuclide ventriculography (MUGA scan) showed localized cardiac dysfunction. The cardiac injury induced by the scorpion venom persisted for a prolonged period.

Chest. 1990;97(6):1480-1481. doi:10.1378/chest.97.6.1480

A 41-year-old woman had Noonan's syndrome. Her heart was complicated by asymmetric septal hypertrophy, hypertrophy of the left ventricular free wall, severe pulmonary stenosis, and right ventricular hypertension. On autopsy, a quantitative histologic analysis of the heart revealed that the area of disarray was limited both to the ventricular septum and the left ventricular free wall as in a normal heart. This is not typical of hypertrophic cardiomyopathy because the extent of disarray is high in most cases of hypertrophic cardiomyopathy. Some form of hypertrophic cardiomyopathy, however, seemed to be present in this patient because right ventricular pressure overload did not affect the left ventricular free wall. To clarify the relation between hypertrophic cardiomyopathy and Noonan's syndrome, quantitative histologic analysis is necessary.

Chest. 1990;97(6):1482-1483. doi:10.1378/chest.97.6.1482

The first fatal Cunninghamella bertholletiae infection in a clinically immunocompetent host is reported. This case differs from previously reported cases by the lack of extensive vascular invasion and thrombosis.

Chest. 1990;97(6):1484-1486. doi:10.1378/chest.97.6.1484

Right-sided valvular (tricuspid, pulmonic) endocarditis is frequently complicated by septic pulmonary embolization. Systemic embolization may also rarely occur due to associated left-sided endocarditis or right-to-left shunting in patients with septal defects. This report documents the occurrence of systemic embolization causing a cerebrovascular accident in an intravenous drug abuser with recurrent tricuspid valve endocarditis due to an isolated peripheral septic pulmonary arteriovenous fistula. Noninvasive diagnosis of the fistula by cardiac auscultation, contrast echocardiography, and nuclear magnetic resonance imaging was confirmed by selective pulmonary angiography. Subselective balloon embolization of the pulmonary arteries feeding this fistula was accomplished.

Chest. 1990;97(6):1486-1488. doi:10.1378/chest.97.6.1486

One case of tricuspid valve endocarditis due to a catheter fragment inside the right chambers of the heart is described. The symptoms were fever, cardiac failure, splenomegaly and relapsing pneumonia. Blood culture was positive, revealing Staphylococcus aureus. A two-dimensional echocardiogram demonstrated a large vegetation on the tricuspid valve. The percutaneous removal of the foreign body allowed complete recovery in a few weeks.

Chest. 1990;97(6):1488-1490. doi:10.1378/chest.97.6.1488

alpha 2-Antiplasmin deficiency is a serious coagulation disorder that results in unrestrained fibrinolytic activity. Clinically, it is manifested by instability of the fibrin hemostatic plug and prolonged or delayed bleeding, which is more serious in patients who are homozygous for this trait. A patient scheduled for aortic valve replacement and coronary bypass presented with a history of repeated episodes of postoperative bleeding. Hemostatic laboratory evaluation revealed that the patient had the heterozygous form of alpha 2-antiplasmin deficiency with a serum concentration of 52 percent (normal, greater than 65 percent of the activity of pooled plasma). He underwent preoperative plasmapheresis with administration of 3,000 ml of fresh frozen plasma, which resulted in an increase in the preoperative level of alpha 2-antiplasmin to 78 percent. Although postoperative blood loss was greater than normal, it was easily managed. Preoperative identification of this rare coagulation abnormality permitted appropriate treatment and probably prevented a postoperative death from hemorrhage.

Chest. 1990;97(6):1490-1492. doi:10.1378/chest.97.6.1490

Marked airway obstruction and interference with gas exchange was encountered following institution of general anesthesia for resection of a cystic subcarinal mass. Intraoperative bronchoscopy revealed marked airway compression. The cyst was decompressed using a transbronchial needle through a fiberbronchoscope. This allowed for safe anesthetic management and resection of the mass.

Chest. 1990;97(6):1492-1493. doi:10.1378/chest.97.6.1492

Catheter-associated candidemia is a common problem in immunocompromised patients. A leukemic patient had Candida right ventricular mural endocarditis complicating an indwelling right atrial catheter. To our knowledge, this is the first reported case of Candida right ventricular mural vegetation visualized by two-dimensional echocardiography.

Chest. 1990;97(6):1494-1496. doi:10.1378/chest.97.6.1494

To illustrate the potential role of transcatheter bronchial artery embolization (TBAE) in the multimodality management of massive hemoptysis, we describe a case in which TBAE was successfully employed as the definitive therapy. In recent years, the technique of TBAE has joined the armamentarium of managing methods for massive hemoptysis. While massive hemoptysis has traditionally been defined in terms of the volume of blood produced within a period of time, with a rate of 600 ml in 24 hours the most commonly used definition, a more functional definition has been proposed: bleeding into the tracheobronchial tree at a rate that poses a threat to life. It is the life-threatening nature of this symptom that often results in the early involvement of thoracic surgeons in the care of these patients.

Chest. 1990;97(6):1496-1498. doi:10.1378/chest.97.6.1496

A patient with Hunter syndrome and diffuse airway obstruction had daytime hypersomnolence, snoring, and alveolar hypoventilation. Polysomnography showed severe obstructive sleep apnea. In the past, all reported cases of sleep apnea in patients with mucopolysaccharidoses had been treated with tonsillectomy/adenoidectomy or tracheostomy. This patient, in whom tracheostomy would have been very difficult due to the diffuse nature of his airway involvement, was successfully treated with high pressure nasal CPAP and supplemental oxygen.

Chest. 1990;97(6):1500-1501. doi:10.1378/chest.97.6.1500
Chest. 1990;97(6):1502a. doi:10.1378/chest.97.6.1502a
Chest. 1990;97(6):1502b-1503. doi:10.1378/chest.97.6.1502b
Chest. 1990;97(6):1504a. doi:10.1378/chest.97.6.1504a
Topics: vancomycin , pain
Chest. 1990;97(6):1504b. doi:10.1378/chest.97.6.1504b

Communications to the Editor

Chest. 1990;97(6):1499. doi:10.1378/chest.97.6.1499-a
Chest. 1990;97(6):1499-1500. doi:10.1378/chest.97.6.1499-b
Chest. 1990;97(6):1501. doi:10.1378/chest.97.6.1501-a
Chest. 1990;97(6):1501-1502. doi:10.1378/chest.97.6.1501-b
Chest. 1990;97(6):1503. doi:10.1378/chest.97.6.1503-a
Chest. 1990;97(6):1503. doi:10.1378/chest.97.6.1503-b
Chest. 1990;97(6):1503. doi:10.1378/chest.97.6.1503-c

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