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Articles

Chest. 1992;101(6):1481-1483. doi:10.1378/chest.101.6.1481
Abstract
Chest. 1992;101(6):1483-1484. doi:10.1378/chest.101.6.1483
Abstract
Chest. 1992;101(6):1484-1486. doi:10.1378/chest.101.6.1484
Chest. 1992;101(6):1486-1487. doi:10.1378/chest.101.6.1486
Abstract
Topics: oxygen , inspiration
Chest. 1992;101(6):1488. doi:10.1378/chest.101.6.1488
Abstract
Topics: weaning
Chest. 1992;101(6):1489-1493. doi:10.1378/chest.101.6.1489

To evaluate the difference in pulmonary gas exchange in patients with and without right ventricular infarction, 147 consecutive patients with their first inferior wall Q-wave acute myocardial infarction were studied. Thirty-nine patients (group 1) had electrocardiographic evidence of right ventricular infarction and it was absent in 108 patients (group 2). A significantly wider alveolar arterial oxygen difference and higher roentgenographic scores were observed in group 1 compared with group 2. Although there were no significant differences in pulmonary artery wedge pressure and colloid osmotic pressure between groups 1 and 2, mean right atrial pressure was significantly higher, while cardiac output and mixed venous oxygen saturation were lower in group 1 compared with group 2. Patients in group 1 had significantly more left ventricular segments with advanced asynergy and higher incidence of proximal right coronary artery lesions than those in group 2. Thus, our data suggest that disorder of pulmonary gas exchange in patients with right ventricular infarction may be explained by increased permeability of the alveolar capillary membrane secondary to larger extent of ischemic myocardium and by hemodynamic abnormalities associated with right ventricular infarction.

Chest. 1992;101(6):1494-1499. doi:10.1378/chest.101.6.1494

In patients, urinary levels of pentamidine have been shown to reflect pulmonary deposition of aerosolized drug. Using urinary levels and air filter samples, we assessed factors responsible for health care worker (HCW) exposure. We measured serial urine samples in HCWs who administered aerosol pentamidine over an 11-month period and compared them with serial urine levels measured over 30 days in a normal volunteer in whose lungs a known amount of pentamidine (3.39 mg) had been deposited. Ambient exposure to pentamidine was determined by continuous high volume air sampling in the treatment room during routine therapy. In addition, the amount of pentamidine released by six HIV-positive subjects, performing tidal breathing with a Respirgard II nebulizer in an airtight booth, was measured by extracting air from the booth through a filter. The effect of adding noseclips, of coughing (with nebulizer shut down), and of removing the nebulizer from the patient's mouth without turning it off, were determined. Pentamidine in the urine of the normal volunteer reached a peak concentration of 9.5 ng/mg creatinine/ml and was detectable for 30 days following the exposure. In HCWs, pentamidine was detected intermittently in four of five individuals with levels as high as 18.2 ng/mg creatinine/ml. Samples of ambient treatment room air indicated small daily releases of pentamidine (0.013 +/- 0.02 mg per patient treated), but simultaneous urine levels in HCWs were negative. The data from the airtight booth revealed that removing the nebulizer from a patient's mouth without turning it off caused a 360-fold increased in pentamidine release compared to tidal breathing. Coughing resulted in a 6.9 (range 0.9-14.2)-fold increase in release, while the addition of noseclips had no significant effect. The pattern of intermittently positive urine tests and the low levels of ambient pentamidine detected in the air of the treatment room suggest that HCWs are being exposed to episodic but high concentrations of pentamidine. High level exposure is most likely to occur during treatment interruptions which are usually precipitated by coughing episodes. Because of the intermittent pattern of exposure and slow clearance of pentamidine, urine assay is useful for detecting high intermittent exposure. Random air sampling is a sensitive indicator of low level exposures but may not detect episodic high level releases.

Chest. 1992;101(6):1500-1506. doi:10.1378/chest.101.6.1500

Uncuffed tracheostomy tubes are used for long-term mechanical ventilation in children. However, upper airway mechanics differ between sleep and wakefulness; this may affect air leak around tracheostomies. We studied 19 children with high cervical spinal cord injury on portable positive pressure ventilators, age range birth to 19 years. Ventilator settings were adjusted while awake to achieve PaCO2 less than 45 mm Hg and PO2 greater than 90 mm Hg. Clinically several children with uncuffed tracheostomies became unstable at night with seizures and sleep disruption. Nine of 11 children on volume controlled systems were found to be inadequately ventilated during sleep. Substitution with a cuffed tracheostomy allowed adequate ventilation both awake and asleep, suggesting that inadequate ventilation during sleep was due to an uncompensated leak around the uncuffed tracheostomy. To avoid cuffed tracheostomies, eight children received pressure controlled ventilation. Gas exchange was adequate throughout the day and night. We conclude that children receiving volume controlled mechanical ventilation via uncuffed tracheostomy tubes can exhibit hypoventilation due to uncompensated air leak. Pressure controlled ventilation improves adequacy of gas exchange during sleep and wakefulness.

Chest. 1992;101(6):1507-1511. doi:10.1378/chest.101.6.1507

To test the hypothesis that the clinical presentation and outcomes are different when pulmonary embolism occurs in younger (age 18 to 40 years) as compared to older (age greater than 40 years) adults, 40 younger patients were compared with older patients. No risk factors could be identified in 28 percent of the younger group. Normal physical examinations were more common (58 vs 28 percent, p = 0.01) among younger as compared with older adults. Hypoxemia was absent in 29 percent of the younger and 3 percent of the older group (p = 0.004); P(A-a)O2 was significantly lower among younger patients even after controlling for age. Mortality was decreased sevenfold (2.5 vs 18 percent, p = 0.03) among younger patients. These data indicate that pulmonary embolism tends to have a subtle presentation in younger adults. When diagnosed and treated, the mortality rate is substantially less among younger as compared with older patients.

Chest. 1992;101(6):1512-1514. doi:10.1378/chest.101.6.1512

The percutaneous femoral vein approach is used routinely for cardiac catheterization in the pediatric age but in some children, it may be impossible as in the case of iliac vein or inferior vena cava thrombosis due to previous cardiac catheterization, or inconvenient as for right ventricular endomyocardial biopsies. In the period between 1982 and 1990, 160 cardiac catheterizations or right ventricular endomyocardial biopsies were performed in 102 children. Patients ranged in age between 2 months and 17 years (mean, 3.8 years) and in weight from 3.2 to 57.3 kg (mean, 14.4 kg). Indications for the internal jugular vein approach were as follows: (1) thrombosis of the inferior vena cava due to previous cardiac catheterization in 42 patients (41 percent); (2) right ventricular endomyocardial biopsy after cardiac transplant in 19 patients (19 percent); (3) control catheterization of the pulmonary arteries following classic or bidirectional cavopulmonary anastomosis in 16 patients (16 percent); (4) superior vena cava obstruction following Mustard's procedure in 14 patients (14 percent); (5) failed percutaneous femoral venous approach in six patients (6 percent); and (6) absence of the hepatic segment of the inferior vena cava in four patients (4 percent). The right or left internal jugular vein could be entered in all but three procedures (98 percent). Seventeen patients had more than one procedure through the same internal jugular vein and the vein was found patent in all. A complete right heart cardiac catheterization was performed using this route. Right ventricular endomyocardial biopsy and interventional procedure were performed through this route. Two major complications occurred. A patient developed a central transient ischemic attack and another patient developed a persistent Horner syndrome. Accidental carotid puncture occurred in five patients without consequences. Our data indicate that cardiac catheterization in infants and children can be performed safely through the internal jugular vein, with a high success rate and a low incidence of major complications.

Chest. 1992;101(6):1515-1520. doi:10.1378/chest.101.6.1515

A series of 32 patients undergoing cardiac catheterization and/or operation to document the presence of patent foramen ovale (PFO) were studied. All were examined by contrast transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) during normal breathing and the Valsalva maneuver. A right-to-left shunt at the atrial level was visualized by contrast TEE in 14 patients during normal breathing and in 20 patients during the Valsalva maneuver. In comparison, contrast TTE revealed this shunt in only eight patients during normal breathing and in 12 patients during the Valsalva maneuver. All of the foramina proved to be patent by contrast TTE were also found by contrast TEE. All but one (19 of 20) patients, shown to have PFO by contrast TEE, could be confirmed at cardiac catheterization and/or operation. Using cardiac catheterization and/or operation as a gold standard, contrast TEE appears to be a more sensitive (100 percent vs 63 percent, p less than 0.005) and accurate (97 percent vs 78 percent, p less than 0.05) method than contrast TTE in the detection of PFO.

Chest. 1992;101(6):1521-1525. doi:10.1378/chest.101.6.1521

This study was conducted to assess esophageal function and pulmonary resistance changes with esophageal acidification in patients with COPD. Twelve patients with COPD and a mean age of 55.6 years were studied. Each patient underwent standard esophageal manometry, 24-h ambulatory pH testing, esophageal acid clearance evaluation during sleep, and an assessment of pulmonary resistance with and without esophageal acid perfusion. Neither airway resistance nor conductance was altered by the esophageal acid infusion; LES pressures were normal and esophageal contractile pressures were mildly decreased. Acid exposure in the upright and supine positions was within normal limits. Acid clearance during sleep was similar to that in normal subjects; however, acid clearance during waking appeared to be somewhat prolonged in the COPD patients. We conclude that patients with COPD do not have a bronchoconstrictive reflex to distal esophageal acidification, and esophageal function in these patients appears to be relatively normal.

Chest. 1992;101(6):1526-1532. doi:10.1378/chest.101.6.1526

We have measured blood pressure continuously with a digital artery blood pressure monitor in eight patients with severe obstructive sleep apnea (OSA) during 30 min each of wakefulness, OSA, OSA with added oxygen to keep saturation above 96 percent at all times (OSA+O2), and nasal continuous positive airway pressure (CPAP) therapy. Mean blood pressures were not different between wakefulness, OSA, OSA+O2, and CPAP, although the variability in blood pressure was significantly greater during OSA and OSA+O2 than during wakefulness and CPAP. The addition of oxygen did not attenuate the variability in blood pressure. Using multiple linear regression modeling to further dissect out the principal variables determining the postapneic blood pressure rise, we found that only apnea length (r2 = 0.28, p less than 0.0001) and pulse rate changes (r2 = 0.15, p less than 0.0001) remained significantly related to SBPmax, while hypoxemia did not. We found the same trends in the other variables SBPten, DBPmax, and DBPten. Hypoxemia made a small contribution to the size of DBPmax, although this was small by comparison with apnea length. We conclude that CPAP treatment of OSA does not lower mean blood pressure acutely, although it significantly reduces the large oscillations in blood pressure seen in patients with untreated OSA. The rise in blood pressure following each apnea is not primarily due to arterial desaturation but is related to apnea length and may be caused by increased sympathetic activity secondary to arousal.

Chest. 1992;101(6):1533-1538. doi:10.1378/chest.101.6.1533

We retrospectively evaluated the clinical effectiveness of a treatment schedule with intermittent positive pressure ventilation via nasal mask in 49 patients with acute exacerbations of COLD. According to the ability to successfully tolerate a preliminary trial with NIPPV, patients were submitted either to standard treatment plus NIPPV (25 patients) or to ST alone (24 patients). The ST consisted of medical, oxygen and physical therapy. The NIPPV was delivered by a volume cycled ventilator in control mode at least 4 h a day for five consecutive days a week, for three weeks. Comparison of baseline with measurements performed after 10 and 21 days of treatment respectively showed a significant improvement in PaO2 and in PaCO2 in both groups. After 21 days of treatment, VC, FEV1, inspiratory muscle strength, and dyspnea significantly improved in both groups. No significant difference was found between groups at any time of treatment. We conclude that the treatment schedule of NIPPV used is not more effective than ST alone in acute exacerbations of COLD.

Chest. 1992;101(6):1539-1544. doi:10.1378/chest.101.6.1539

Anecdotal reports suggest that obstructive sleep apnea syndrome (OSAS) patients may suffer from frequent nocturnal gastroesophageal reflux (GER) and that nasal continuous positive airway pressure may be an effective form of antireflux therapy in this population. To confirm these clinical impressions, we performed two consecutive days of 24-h esophageal pH monitoring, nocturnal esophageal pressure recording, and polysomnography on six OSAS patients complaining of regular nocturnal GER. On night one, the patients were untreated. Five of six subjects had abnormal amounts of nocturnal GER. Arousal, movement and swallowing were more frequent (p less than 0.043) and nadir intrathoracic pressure lower (p less than 0.005) in the 30 s prior to precipitous drops in esophageal pH (greater than or equal to 2 pH units) than during random control periods. A direct association between obstructive apneas and GER was not identified. On night two, nasal CPAP was administered and successfully treated apnea in five of six subjects. In these patients, there was also dramatic reduction in GER frequency and duration on CPAP. The mean percentage of time pH less than 4 dropped from 6.3 +/- 2.1 to 0.1 +/- 0.1 percent (p less than 0.025). We believe that OSAS may predispose to nocturnal GER by lowering intrathoracic pressure and increasing arousal and movement frequency. Nasal CPAP can correct these predisposing factors and reduce GER.

Chest. 1992;101(6):1545-1551. doi:10.1378/chest.101.6.1545

STUDY OBJECTIVE: Our objective was to compare the differential effects of age and drug type on bronchodilator response. DESIGN: The design was an unblinded, randomized crossover study. SETTING: An ambulatory pulmonary drug study unit was the setting. PATIENTS: Nineteen young (18 to 25 yr) and 17 elderly (greater than 65 yr) stable asthmatic subjects were studied. INTERVENTIONS AND MEASUREMENTS: Albuterol or ipratropium was given on two separate mornings using an MDI with extender. Subjects inhaled two puffs initially and then one puff every 30 min to a total of six puffs. Pulmonary function, blood pressure, and pulse were measured at baseline and every 30 min for 3 h. RESULTS: All subjects had a greater than 15 percent increase in FEV1 with one or both drugs. More patients responded to albuterol than to ipratropium in both age groups. The maximum percentage of change from baseline was greater (p less than 0.05) with albuterol (mean, 40.1 percent in young and 60.5 percent in old) than with ipratropium (21.2 percent in young; 31.2 percent in old) in both groups. These differences remain significant after correction for baseline differences using area-under-the-curve analysis of the percent of maximum improvement; however, the differences between age groups for the same drug were not statistically significant by either index of change. There were also no differences between drugs or between age groups for time (or number of puffs) to reach maximum improvement (mean, 2.0 to 2.2 h for albuterol and 1.6 to 1.7 h for ipratropium). The changes in FVC and FEF25-75% were similar to FEV1. Changes in blood pressure and pulse were not significant. Three subjects stopped therapy with albuterol with side effects. CONCLUSIONS: Both drugs are effective bronchodilators in young and old asthmatic subjects, but albuterol results in a greater magnitude of response in both age groups. Age is not a predictor of response to either drug.

Topics: bronchodilator
Chest. 1992;101(6):1552-1557. doi:10.1378/chest.101.6.1552

A survey of four inhaled beta-agonist agents was evaluated as a means of selecting the optimum agent for chronic therapy in patients with stable COPD. Eighteen patients completed as protocol of prebronchodilator and postbronchodilator spirometry utilizing albuterol, metaproterenol, pirbuterol, and terbutaline daily in random order. Subsequently, each patient received treatment with either the greatest or least response-invoking agent for four weeks, followed by a second interval with the opposite agent. At the end of each interval, the results of repeat spirometry, arterial blood gas determinations, 12-min walks, dyspnea questionnaires, and self-monitored peak expiratory flow rates were recorded. Use of the greatest response-invoking agent resulted in significantly larger prebronchodilator and postbronchodilator FEV1 and FVC. No other study factor was significantly different. Acute bronchodilator surveys may have a role in medication selection in view of the improvement in spirometric volumes.

Chest. 1992;101(6):1558-1562. doi:10.1378/chest.101.6.1558

Pulmonary surfactant is altered in experimental Pneumocystis carinii pneumonia. Although P carinii is a major causative agent of pneumonia in immunocompromised patients, the pathophysiology of lung injury caused by this organism is poorly understood. Therefore, we studied bronchoalveolar lavage specimens obtained from 19 HIV-infected subjects with PCP compared with specimens from ten healthy control subjects. As iterative BAL was performed, 37 BAL specimens were analyzed for protein and phospholipid. The BAL samples were divided into two groups as follows: 22 BAL samples with the presence of P carinii and 15 BAL samples without P carinii. Compared to control subjects, HIV+ BAL presented a significant increase of PR and a decrease of total PL in both P carinii+ and P carinii- BAL, but in P carinii+ BAL, the fall of PL/PR ratio was significantly more pronounced compared to P carinii- (0.09 +/- 0.02 vs 0.19 +/- 0.04, p less than 0.02). The BAL performed during the recovery of PCP showed an improvement of initial biochemical abnormalities. Surfactant composition was also altered, with a phosphatidylcholine and phosphatidylglycerol drop and a sphingomyelin and lysophosphatidylcholine increase. The presence, even in P carinii- BAL, of less polar compounds of undetermined nature, was revealed. We concluded that in HIV+ patients, abnormalities of pulmonary surfactant were present before PCP, and that the development of PCP enhances these abnormalities. These surfactant alterations may contribute to the saprophyte-pathogen transformation of P carinii, but this hypothesis requires further investigation that is presently in progress.

Chest. 1992;101(6):1563-1568. doi:10.1378/chest.101.6.1563

We evaluated tolerance, safety, and effects on lung function and bronchial responsiveness of BAL (4 x 50 ml) combined with BB (three to five specimens) performed without premedication in 13 mild and stable asthmatics and eight healthy volunteers. All subjects tolerated bronchoscopy procedures well and without serious side effects. During procedures, no supplemental oxygen was administered and no ECG abnormalities were noted. The PEFR was measured before and immediately after bronchoscopy and at 5-min intervals up until recovery. The maximal percentage fall in PEFR after bronchoscopy was significantly greater in asthmatics (23.1 +/- 13.9 percent) compared to normal subjects (7.8 +/- 8.2 percent, p less than 0.01). Changes in PEFR returned to baseline values within 120 min in all asthmatics. The tcPO2 was recorded at baseline, during and after bronchoscopy. In both groups, a significant change in tcPO2 was measured during the infusion of BAL aliquots, and persisted throughout the procedure. A significant difference in asthmatics compared to healthy subjects was evident during BB and at the end of the procedure (p less than 0.05). In asthmatics, M challenge was performed on three different days over a three-week period prior to bronchoscopy, and was repeated at intervals of 2, 6, and 24 h following procedure. The PC20 M values measured before bronchoscopy were found to have a very high reproducibility (intraclass correlation coefficient = 0.93). The PC20 values measured during experiment times after bronchoscopy were not significantly different from baseline values. These data demonstrate that in mild and stable asthmatics, BAL combined with BB can be safely performed following administration of only local anesthesia. In carefully selected asthmatic subjects, transient bronchoconstriction and a lowering of oxygen tension can be induced by BAL and BB, whereas changes in bronchial responsiveness are more unlikely to occur.

Chest. 1992;101(6):1569-1576. doi:10.1378/chest.101.6.1569

A survey was made within a population of workers (n = 706) exposed to hard metal dust (an alloy including cobalt), an agent known to cause occupational allergy. Twenty-seven (4 percent) of 733 workers were eliminated from consideration in this study because of atopic status identified prior to starting work in the plant. Using a Phadebas PRIST, the subjects' total IgE levels were determined and related to their smoking and exposure status. Nonexposed male smokers (n = 135) had a higher geometric mean IgE level (39.7 IU/ml) than did nonexposed subjects who had never smoked (33.1 IU/ml; n = 99); those with a higher Brinkman index (greater than 300), a smoking index obtained by multiplying the number of cigarettes per day by the duration of smoking in years, had significantly (p less than 0.05) decreased IgE levels. Although ex-smokers (n = 72) had a higher geometric mean IgE level (73.3 IU/ml) than did those who had never smoked, their serum IgE level declined with age since the time they quit smoking, regardless of their hard metal exposure status. Hard metal (cobalt) exposure may play a significant role as an adjuvant in the production of total IgE. A multivariate analysis demonstrated that hard metal exposure and a smoking habit together arithmetically (p less than 0.05) increased total IgE levels. These two factors may be preventable risk factors for occupational allergy in hard metal workers.

Chest. 1992;101(6):1577-1581. doi:10.1378/chest.101.6.1577

Patients with suspected reversible airways obstruction (RAO) sometimes report subjective benefit after bronchodilator treatment despite no objective spirometric improvement. One possible explanation for this is improvement in volume-related or plethysmographic parameters in the absence of spirometric improvement. One hundred patients with RAO were assessed before and after inhaled bronchodilator to determine the prevalence of improvement by plethysmographic parameters in the absence of improvement in spirometric parameters. Spirometry alone (FEV1, FVC, and FEF25-75%) identified reversibility of airflow limitation in 82 patients. Reversibility was identified by body plethysmography (specific conductance [SGaw], thoracic gas volume [TGV], and isovolume maximum expiratory flow rates [IVMEF]) in 15 of the remaining patients. The percent predicted FEF25-75% at baseline was higher in patients who required plethysmography to identify reversibility, but could not be used to predict the lack of a spirometric response for any individual patient. We conclude that spirometry alone fails to identify reversibility in approximately 15 percent of patients, and that most of these patients can be identified by additional plethysmographic measurements of volume-related parameters. At any one point in time, multiple tests must be used together to adequately identify the majority of patients with reversible airways obstruction. Improvement in volume-related parameters may explain why some patients with RAO improve subjectively with bronchodilators but show no spirometric improvement.

Chest. 1992;101(6):1582-1587. doi:10.1378/chest.101.6.1582

The oxygen consumption (VO2)/oxygen delivery (DO2) relationship was analyzed in ten patients with severe congestive heart failure (CHF) and normal blood lactate levels. First dobutamine and then enoximone, after a washout period, were administered to each patient to increase cardiac output by at least 15 percent. Similar increases in DO2 were obtained with both drugs: from 285 +/- 46 to 393 +/- 87 ml/min/m2 for dobutamine, and from 285 +/- 54 to 392 +/- 99 ml/min/m2 for enoximone. However, while VO2 did not change (132 +/- 24 vs 132 +/- 21 ml/min/m2) (VO2/DO2 independency) with a dobutamine infusion (mean dose of 10 +/- 2 micrograms/kg/min), a significant increase in VO2 from 134 +/- 22 to 157 +/- 21 ml/min/m2 was observed with a bolus infusion of enoximone (mean dose of 1.7 +/- 0.5 mg/kg). These results, observed in patients with CHF without patent oxygen debt, suggest that an artefactual VO2/DO2 dependency might be induced by the cardiovascular drug used to elevate DO2, probably because of a drug-induced oxygen demand increase.

Chest. 1992;101(6):1588-1590. doi:10.1378/chest.101.6.1588

Fifteen patients with different degrees of chronic bradyarrhythmias of supraventricular origin were studied with Holter monitoring before and during application of a transdermal patch of scopolamine. No changes were found in the mean or minimal heart rates, standard deviation of the RR interval, or the degree of bradyarrhythmia. It is concluded that transdermal scopolamine is not an adequate treatment of chronic symptomatic bradyarrhythmias.

Chest. 1992;101(6):1591-1596. doi:10.1378/chest.101.6.1591

In untreated patients with uncomplicated essential hypertension, exercise induces an abnormal increase in blood pressure; the influences of this increase on exercise were evaluated by a cardiopulmonary exercise test (CPX) performed in control conditions (step 1) and during acute blood pressure reduction (step 2). Patients were classified as (1) normotensive (resting diastolic blood pressure [BPd] less than 90 mm Hg; n = 14), (2) mildly hypertensive (BPd of 90 to 104 mm Hg; n = 9), and (3) moderately to severely hypertensive (BPd greater than or equal to 105 mm Hg; n = 16). For the three groups, peak mean blood pressure during exercise was 125 +/- 5 mm Hg (mean +/- SEM), 144 +/- 3 mm Hg (p less than 0.01 vs normotensive), and 161 +/- 4 mm Hg (p less than 0.01 vs normotensive and p less than 0.01 vs mild hypertension), respectively. Oxygen consumption (VO2) at peak exercise and at ventilatory anaerobic threshold was 26.1 +/- 1.1 and 17.2 +/- 0.5 ml/min/kg, 25.4 +/- 1.1 and 16.9 +/- 0.8 ml/min/kg, and 26.4 +/- 1.3 and 17.5 +/- 1.2 ml/min/kg in normotensive subjects, those with mild hypertension, and those with moderate to severe hypertension, respectively. Fourteen normotensive subjects, six with mild hypertension, and nine with moderate to severe hypertension participated to step 2 (nifedipine vs placebo, double-blind crossover). Nifedipine reduced blood pressure at rest and at peak exercise in those with hypertension. Peak exercise VO2 was unaffected by nifedipine in both normotensive subjects and those with hypertension. With nifedipine, ventilatory anaerobic threshold occurred earlier and at a lower VO2 in mild and in moderate to severe hypertension (delta VO2 = -1.9 and -2.4 ml/min/kg, respectively). These findings might be due to nifedipine-induced redistribution of blood flow during exercise and might be the reason for the complaint of weakness after blood pressure reduction in hypertensive subjects.

Chest. 1992;101(6):1597-1600. doi:10.1378/chest.101.6.1597

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary thromboembolic disease are difficult to diagnose, particularly following surgery. This report demonstrates the use of 111In-labelled platelet-specific monoclonal antibody, P256 Fab', for the diagnosis and study of the time course of thromboembolic disease in a patient following total hip replacement. METHOD: One hundred micrograms of pentetic acid (DTPA)-P256 Fab' was labelled with 8 to 10 MBq of 111In chloride by incubation at room temperature for 15 min. After dilution in physiologic saline, the tracer was injected intravenously on the third and sixth days postoperatively. Imaging of the chest, pelvis, and legs was carried out at 24, 48 and 72 h following each injection. RESULTS: The first image four days after surgery demonstrated activity in the right heart which moved to the right pulmonary artery on the following day. Activity was seen in both femoral veins; on the left, this increased over two days, followed by a reduction on the seventh day after surgery, at which time new activity was seen in the right heart. After a further two days, this activity moved to the left pulmonary artery. The DVT was confirmed by venography and the pulmonary embolism (PE) by ventilation perfusion scan. CONCLUSIONS: 111Indium-labelled platelet-specific monoclonal antibody, P256 Fab', provides a technique for studying the natural history of thromboembolic disease and its treatment.

Chest. 1992;101(6):1601-1604. doi:10.1378/chest.101.6.1601

This study was to determine whether the PCONCO2 and PCONO2 which collect in the expiratory trap of a ventilator circuit are equivalent to PECO2 and PEO2. Fifty studies were performed in 34 mechanically ventilated male patients. Five milliliters of condensate fluid were collected and PECO2 and PEO2 were measured. Exhaled gases were collected simultaneously with condensate fluid for 5 min in a meteorologic balloon and FECO2 and FEO2 were measured; PECO2 and PEO2 were then calculated. The mean PECO2 was not significantly different from PCONCO2 nor was the PCONO2 significantly different from the condensate PCONO2. There was a high correlation between mixed expired PECO2 and PCONCO2 as well as PEO2 and PCONO2. These data indicate expiratory PCONCO2 and PCONO2 provide a valid reflection of PECO2 and PEO2. The PCONCO2 and PCONO2 measured in a clinical blood gas analyzer are accurate and may be used in calculation of VD/VT and in metabolic assessments.

Chest. 1992;101(6):1605-1609. doi:10.1378/chest.101.6.1605

BACKGROUND: Pulmonary disease due to Mycobacterium avium complex (MAC-PD) radiographically resembles that due to tuberculosis; it preferentially affects elderly white men with predisposing pulmonary disorders (PDPD). METHODS: Twenty-nine patients with MAC-PD were identified from a community-based population, and the medical records and chest roentgenograms (CRs) of six with a previously undescribed pattern of MAC-PD were reviewed. The distinctive clinical and demographic features of these six patients were identified and summarized. RESULTS: All were women who tended to be elderly. None had clinically evident PDPD. The dependent portion of the lingula or its counterpart, the middle lobe, was initially affected. Hilar adenopathy, volume loss, and cavitary disease were uniformly absent. CONCLUSIONS: To account for the distinctive features of this syndrome, we offer the hypothesis that habitual voluntary suppression of cough may have led to the development of nonspecific inflammatory processes in these poorly draining lung regions, upon which MAC-PD engrafted. We offer the term, Lady Windermere's syndrome, to describe this pattern among elderly women and to suggest that their fastidiousness may be its root cause.

Chest. 1992;101(6):1610-1613. doi:10.1378/chest.101.6.1610

Five cases of bronchogenic carcinoma were observed among 93 patients with pulmonary histiocytosis X (Hx). Mean age at the time of diagnosis of Hx was 42 years; on the average, cancer occurred 10.5 years later. All patients were smokers and continued to smoke heavily at the time of diagnosis of cancer. Comparison of the five cases associating Hx and lung carcinoma with a group of 88 control patients suffering from Hx alone suggested that smoking played the predominant role in the pathogenesis of cancer. In fact, among the four patients with Hx and carcinoma older than 45 years, tobacco consumption was significantly greater (64.7 +/- 37 pack-year, mean +/- SD) than that of the 15 control patients of the same age with only Hx (40.8 +/- 11.6, p less than 0.01). In light of this good correlation, the diagnosis of Hx strongly advocates stopping tobacco smoking and long-term medical follow-up.

Chest. 1992;101(6):1614-1618. doi:10.1378/chest.101.6.1614

Lung mucociliary clearance was measured using an objective, noninvasive radioaerosol technique in 13 patients with pulmonary sarcoidosis and 13 matched, healthy control subjects. Four of the sarcoid patients had never received any steroid therapy, five were currently receiving oral corticosteroids, and the remaining four were using inhaled corticosteroids only. A statistically significant retardation in tracheobronchial clearance (p less than 0.02) was observed in the sarcoid patients compared to the control subjects. The sarcoid patients using inhaled corticosteroids appeared to demonstrate the greatest degree of mucociliary transport impairment. The sarcoid patients in apparent remission and those receiving oral corticosteroid therapy had clearances better than those using inhaled corticosteroids, but they were still reduced compared to the control subjects. This study demonstrates that lung mucociliary clearance is adversely affected in patients with pulmonary sarcoidosis and raises the question of the possible consequences that could follow long-term inhaled immunosuppressive therapy on the prime clearance defense mechanism within the human lungs.

Chest. 1992;101(6):1619-1624. doi:10.1378/chest.101.6.1619

The finding of a dependence of oxygen consumption on oxygen delivery in critically ill patients has encouraged interventions to increase oxygen delivery index (DO2I) to overcome tissue hypoxia. In individuals other factors may influence oxygen consumption index (VO2I) and DO2I and may cause an apparently dependent relationship. We studied the effects of sedation and temperature on the VO2I/DO2I relationship in 13 perioperative patients. Pooled data showed significant correlations between VO2I and DO2I (r greater than 0.6, p less than 0.05) but also between VO2I and sedation score (r greater than 0.7, p less than 0.05), but not VO2I and temperature (r less than 0.5). When VO2I was standardized for the effects of sedation score (SS), the relationship between VO2I and DO2I was lost (r less than 0.5). Seven of 13 patients had significant (p less than 0.05) correlations between VO2I and SS and six of 13 between VO2I and DO2I; when standardized for the effect of varying sedation, no relationships were significant. When interpreting oxygen transport data from critically ill patients, the effects of sedation but not temperature must be taken into account; otherwise a false impression of a dependent relationship between VO2I and DO2I may cause unnecessary treatment.

Chest. 1992;101(6):1625-1632. doi:10.1378/chest.101.6.1625

Control of pain, discomfort, and agitation is an integral part of the postoperative management of critically ill patients. We examined the sedative and analgesic practices in a surgical ICU during two six-month periods, one in 1986-1987 and the other in 1989-1990. Narcotics, especially morphine and Fentanyl, were the most commonly used drugs. The amount of Fentanyl received by the endotracheal patients in the 1986-1987 group was quite large, 5.5 +/- 4.3 (SD) mg/day. The use of midazolam during the second survey period was associated with a reduced dose of narcotics in artificially ventilated patients receiving continuous intravenous Fentanyl and morphine. The use of epidural Fentanyl, especially following thoracic surgery, was greatly increased during the second study period. More work is needed to assess the effects and effectiveness of ICU sedative and analgesic regimens.

Chest. 1992;101(6):1633-1638. doi:10.1378/chest.101.6.1633

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.

Chest. 1992;101(6):1639-1643. doi:10.1378/chest.101.6.1639

Failure of weaning from mechanical ventilation in COPD patients is often related to diaphragmatic fatigue. Whether there is a central respiratory drive fatigue and a reserve of excitability is still debated. The purpose of this study was to analyze the following in 13 COPD patients weaned from mechanical ventilation: (1) ventilatory (VE/PETCO2) and neuromuscular (P0.1/PETCO2) response to hypercapnia; (2) the maximum reserve capacity measured through changes in the VE/PETCO2 and P0.1/PETCO2 slopes after doxapram (DXP) infusion, which, given during the test, allows measurement of the maximum response capacity to overstimulation; and (3) analyze the influence of these changes on the outcome of weaning. The results show a variable P0.1/PETCO2 response and a low VE/PETCO2. DXP infusion does not change the slopes of these relations but increases the end-expiratory volume (delta FRCd); (p less than 0.02). Since there was no change in the VE/PETCO2, P0.1/PETCO2, and delta FRC values with or without DXP, there was no excitability reserve in patients who were successfully weaned. When weaning failed, DXP did not change VE/PETCO2 and P0.1/PETCO2 slope, but delta FRCd was greater the delta FRC (p less than 0.001). The excitability reserve in these patients leads to an increase in end-expiratory volume, probably worsening the diaphragm dysfunction.

Chest. 1992;101(6):1644-1655. doi:10.1378/chest.101.6.1644

An American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference was held in Northbrook in August 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic parameters by which a patient may be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods when dealing with septic patients was recommended as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended. The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.

Chest. 1992;101(6):1656-1662. doi:10.1378/chest.101.6.1656

OBJECTIVE: To evaluate the current definitions for sepsis and clarify and quantify the risk for intensive care unit (ICU) patients with sepsis. DESIGN: A prospective cohort analysis of 519 patients with a primary clinical diagnosis of sepsis treated in the ICUs of 40 US hospitals drawn from a nationally representative sample of 17,440 admissions. MEASUREMENTS: Patient's age, treatment location prior to ICU admission, comorbidities, origin of sepsis, daily physiologic measurements, therapeutic intensity, and subsequent hospital mortality rate. INTERVENTION: Patients were categorized into subgroups by important risk factors and into current clinical definitions of sepsis. Patients also were provided an individual risk of hospital mortality based on their individual predicted risk by using the first ICU day APACHE III score, treatment location prior to ICU admission, and etiology of sepsis. RESULTS: Patients with a designated urinary source of sepsis had a significantly lower baseline risk of death (30 percent) than patients with other causes (54 percent, p less than 0.01). Patients admitted to the ICU from the emergency department also had significantly lower mortality (37 percent) than patients admitted from hospital wards, other units within the hospital, or transferred from other hospitals (55 percent, p less than 0.01). Recognized definitions such as "sepsis syndrome" and "septic shock" identified groups of patients with significantly different mortality rates, 40 percent and 64 percent, respectively (p less than 0.01), but the range of individual patient risks within these groups were indistinguishable from the 211 patients (41 percent) that did not meet these definitions during the initial seven days of ICU treatment. Multivariate analysis using initial APACHE III score, etiology (urosepsis or other), and treatment location prior to ICU admission provided the greatest degree of discrimination (ROC = 0.82) of patients by risk of hospital death. CONCLUSIONS: Sepsis is a complex clinical entity and could be viewed as a continuum with substantial variation in initial severity and risk of hospital death. One accurate description of sepsis is the continuous measure of hospital mortality risk estimated primarily from physiologic abnormalities.

Topics: sepsis , septicemia
Chest. 1992;101(6):1663-1673. doi:10.1378/chest.101.6.1663

Fibronectin, a dimeric cell-adhesive extracellular matrix glycoprotein, is secreted by mesenchymal cells and assembled into insoluble matrices which have important biological functions in embryologic development as well as in tissue response to injury. Fibronectin interacts with numerous cell types including mesenchymal cells and inflammatory cells which bear appropriate fibronectin receptors. In vitro, fibronectin serves as an adhesive substrate and promotes cell proliferation and cytodifferentiation. During development, fibronectin-rich matrices are deposited in specific location and regulate the directional migration of embryonic cells. In particular, fibronectin matrices appear to be of critical importance to normal cardiopulmonary development. Following embryologic development, the tissue expression of fibronectin is greatly reduced, but increases markedly following tissue injury, where newly expressed fibronectin matrices appear critical to tissue repair. Recent evidence has documented increased expression of fibronectin in numerous pulmonary conditions including the adult respiratory distress syndrome (ARDS), bronchiolitis obliterans organizing pneumonia (BOOP) and idiopathic pulmonary fibrosis (IPF). Additionally, fibronectin also interacts with a large number of microorganisms and therefore also is potentially important in microbial adherence to airway epithelium and subsequent infections of the respiratory system.

Chest. 1992;101(6):1674-1676. doi:10.1378/chest.101.6.1674

A patient with a previously unsuspected intrathoracic tracheal malignancy presented with symptoms suggestive of asthma and an unusual pattern seen by conventional PFTs. Reduced expiratory flows with a large difference between FVC and SVC, normal inspiratory flows and high MVV/FEV1 were found. Body plethysmography using normal and panting efforts with increasing tidal volume and flow helped define the lesion as a variable intrathoracic obstruction and document its regression after palliative therapy.

Chest. 1992;101(6):1677-1678. doi:10.1378/chest.101.6.1677
Chest. 1992;101(6):1679-1680. doi:10.1378/chest.101.6.1679
Abstract
Chest. 1992;101(6):1681-1683. doi:10.1378/chest.101.6.1681

We used capnometry during high-frequency oscillatory ventilation (HFOV), and compared CO2 measurements at the distal and proximal ends of an endotracheal tube with arterial CO2 values. Ten white rabbits (mean weight, 2.00 +/- 0.2 [SD] kg) underwent tracheostomy under anesthesia with pentobarbital. The trachea was intubated with an endotracheal tube with a second lumen for sampling respiratory gas at the distal tip. Capnometry was performed through the lumen (CO2d) and the proximal end of the endotracheal tube (CO2p). The internal carotid artery was cannulated to sample blood for measuring arterial blood gases. The differences between CO2d, CO2p, and PaCO2 were measured. Only the relation between CO2d and PaCO2 was good (r = 0.915). We concluded that capnometry can be used during HFOV to estimate PaCO2 provided that respiratory gas is sampled from the distal tip of the endotracheal tube.

Chest. 1992;101(6):1684-1690. doi:10.1378/chest.101.6.1684

We employed a canine model of coronary thrombosis, induced by injection of radioactive blood clot, via a catheter placed in the left anterior descending coronary artery, to compare effects of intracoronary administration of recombinant tissue plasminogen activator (rtPA) and urokinase (UK) on rate and extent of coronary thrombolysis. Two doses of UK, 15,000 U/kg (UK15) and 30,000 U/kg (UK30) and two doses of rtPA, 0.25 mg/kg (rtPA.25) and 0.75 mg/kg (rtPA.75) were given. Drugs were infused over 45 min. Compared with the other regimens, rate and extent of coronary thrombolysis were significantly increased with rtPA.75. Also, despite a much higher dose of UK, coronary thrombolysis was similar with UK30 and rtPA.25. Compared with UK15, rate and extent of coronary thrombolysis were increased with rtPA.25. These results indicate that intracoronary administration of rtPA is superior to intracoronary UK in inducing thrombolysis.

Chest. 1992;101(6):1691-1693. doi:10.1378/chest.101.6.1691

Erythrocytosis, a known response to chronic hypoxemia, is considered infrequent in interstitial lung diseases. We studied the prevalence of high hematocrit (Hct) values and the relationship between Hct and SaO2 in 79 patients with chronic pigeon breeder's lung (PBL) and 34 with idiopathic pulmonary fibrosis (IPF), all of whom lived in the Mexico City metropolitan area (2,240 m above sea level). Lung biopsy was performed in 31 patients with IPF and 71 with PBL. We analyzed only one simultaneous measurement of Hct and SaO2 per patient (usually the initial measurement) before treatment. No additional cause for anemia or erythrocytosis was detected. Forty-eight percent of the patients with PBL (38/79) and 62 percent of those with IPF (21/34) had high Hct values (greater than 2 SD above mean values for Mexico City); in 14 (12.3 percent) of the 113 patients (nine with PBL and five with IPF), the Hct was above 60 percent. The Hct and SaO2 values displayed a poor correlation for the whole group: Hct = 65.7-0.16(SaO2), r = 0.24, p = 0.012. The correlation between Hct and SaO2 was nonsignificant if patients were separated by diagnosis. For an SaO2 of less than 80 percent, the slope of SaO2 vs Hct was zero. Half of our patients with PBL and IPF had Hct values that were high for the altitude. In most cases, Hct responses fell within the confidence limits reported as normal at high altitudes. We found a poor relationship between Hct and awake SaO2.

Chest. 1992;101(6):1694-1698. doi:10.1378/chest.101.6.1694
Abstract
Topics: physiology
Chest. 1992;101(6):1699-1702. doi:10.1378/chest.101.6.1699
Chest. 1992;101(6):1703-1705. doi:10.1378/chest.101.6.1703
Abstract
Topics: asthma , heart
Chest. 1992;101(6):1706-1707. doi:10.1378/chest.101.6.1706

A 54-year-old woman with pseudoxanthoma elasticum presented with tight mitral stenosis with thickened and restricted mitral valve leaflets. She initially revealed systemic hypertension and moderate mitral regurgitation due to mitral valve prolapse. One year after the start of treatment for hypertension, thickening of the mitral valve gradually progressed and she showed tight mitral stenosis without regurgitation. It was considered that another differential diagnosis must be added to the uncommon causes of mitral stenosis.

Chest. 1992;101(6):1708-1709. doi:10.1378/chest.101.6.1708

Three radiologically and bacteriologically confirmed pulmonary tuberculosis patients had eosinophilic pneumonia, as demonstrated by BAL. In two patients, pulmonary eosinophilia was present only at the site of the lesion and the third had eosinophilia in both peripheral blood and lung. There was complete elimination of the eosinophilic inflammatory process in two patients who had successfully completed antituberculosis treatment.

Chest. 1992;101(6):1710-1711. doi:10.1378/chest.101.6.1710

Pulmonary microvascular cytology consists of analysis of capillary blood sampled while a Swan-Ganz catheter is in the wedge position. This technique has proved to be useful in the diagnosis of lymphangitic spread of carcinoma in the lungs and there are case reports of their use in amniotic fluid embolism. Its usefulness in diagnosing fat embolism syndrome has been shown only rarely. We report a new case in which pulmonary microvascular cytologic study allowed a definite diagnosis of fat embolism syndrome. We suggest obtaining routinely samples of capillary blood when a pulmonary catheter is in place and fat embolism is suspected on a clinical basis.

Topics: lung , cytology , fat embolism
Chest. 1992;101(6):1712-1713. doi:10.1378/chest.101.6.1712

Two patients eventually shown to have empyema were encountered in which the initial thoracentesis revealed fluid compatible with either a simple or a complicated parapneumonic effusion. In both cases, the diagnosis of empyema was made by a second thoracentesis done at a close interval of time from a different site. Therefore, the physician should approach parapneumonic effusions systematically, and remember that in some cases, multiple thoracenteses may be required to make the correct diagnosis of an empyema.

Topics: empyema
Chest. 1992;101(6):1714-1715. doi:10.1378/chest.101.6.1714

A 57-year-old man with small cell lung carcinoma developed benign, obstructing endobronchial bands five months after external beam radiation therapy. We believe that this represents an unusual delayed complication of radiation therapy for airway tumors. An excellent clinical response was obtained after laser ablation of the lesion.

Chest. 1992;101(6):1715-1716. doi:10.1378/chest.101.6.1715

A 29-year-old man presented with a four-week history of pneumonic symptoms and progressive roentenographic infiltrates which were unresponsive to orally administered antibiotics. Bronchoscopy failed to identify an infectious etiology, but abundant atypical lymphocytes in the bronchial washings were present. A diagnosis of adult T-cell leukemia/lymphoma was subsequently made. After administration of cancer chemotherapy, the pneumonic symptoms and chest roentgenogram infiltrates resolved. This report suggests that ATL can present as an acute noninfectious pneumonitis.

Chest. 1992;101(6):1717-1718. doi:10.1378/chest.101.6.1717

Respiratory syncytial virus (RSV) has been documented as a pathogen in adults who are immunocompromised because of various underlying conditions. To our knowledge, this is the first report of a patient with Wegener's granulomatosis (WG) and RSV infection resulting in a fatal outcome.

Chest. 1992;101(6):1718-1719. doi:10.1378/chest.101.6.1718

Hemianomalous pulmonary venous connection is a rare congenital abnormality that leads to significant left-to-right shunt and complications related to that. Earlier surgical correction of this disorder was associated with the problem of stenosis at the anastomotic site with the left atrium. We describe the diagnosis of this abnormality in a 24-year-old woman and present the details of surgery to avoid the stenosis at the site of anastomosis.

Topics: lung , left lung
Chest. 1992;101(6):1720-1722. doi:10.1378/chest.101.6.1720

A patient with occupational asthma in the beet sugar processing industry is described. Symptomatology, skin testing, immunologic testing, and specific bronchoprovocation testing indicate exposure to moldy sugar beet pulp was the cause of the patient's occupational asthma. Cooperation between the treating physician and public health authorities is encouraged.

Chest. 1992;101(6):1722-1723. doi:10.1378/chest.101.6.1722

Direct extention of bronchogenic carcinoma via pulmonary veins into the left atrium is rare. We describe two such cases, one which presented as a left atrial mass with pulmonary edema, and another which was detected at autopsy.

Chest. 1992;101(6):1724-1726. doi:10.1378/chest.101.6.1724

Two women, aged 44 and 29 years, respectively, were admitted to the hospital in early 1987 for recurrent pneumothorax, dyspnea and a diffuse reticulonodular pattern evidenced on the chest x-ray film. Lung biopsy confirmed LAM in both patients. Both were treated sequentially with medroxyprogesterone and a LHRH agonist (buserelin) to achieve reversible medical castration. Neither subjective nor objective improvement was noted after 13 and 5 months, respectively, of buserelin therapy (900 micrograms/day, nasal spray) despite an effective suppression of the pituitary-gonadal axis. Medroxyprogesterone also was ineffective. Buserelin thus failed to control pulmonary LAM in these two patients, in spite of effective medical castration.

Chest. 1992;101(6):1726-1728. doi:10.1378/chest.101.6.1726

Multifocal atrial tachycardia (MAT) is a supraventricular tachydysrhythmia precipitated by a number of pharmacologic and physiologic disturbances. Corrections of these disturbances should take precedence in the treatment of MAT.

Chest. 1992;101(6):1728-1730. doi:10.1378/chest.101.6.1728

A patient with a cervical cord transection isolating his hypothalamic thermoregulatory centers from peripheral effectors suffered a fatal hyperthermic episode after receiving haloperidol. This suggests that neuroleptic malignant syndrome is caused by a peripheral, not central, effect of haloperidol.

Chest. 1992;101(6):1730-1732. doi:10.1378/chest.101.6.1730

This case report describes the evolution of an acute anteroseptal myocardial infarction in a 27-year-old man following intravenous injection of pentazocine and tripelennamine. Subsequent coronary angiography showed normal coronary arteries. Based on the known mechanism of action of these drugs, it is postulated that myocardial infarction resulted from coronary artery spasm secondary to excessive catecholamine stimulation.

Chest. 1992;101(6):1732-1733. doi:10.1378/chest.101.6.1732

Two cases of infective endocarditis with vegetations attached to the mitral and tricuspid annuli are described. In both cases, the vegetations could not be identified by transthoracic echocardiography. These cases illustrate the advantage of TEE over the transthoracic approach in recognizing vegetations in extravalvular locations.

Chest. 1992;101(6):1733-1736. doi:10.1378/chest.101.6.1733

The manifestations of cardiac mucormycosis may dominate the clinical picture of disseminated mucormycosis. These manifestations include myocardial infarction, congestive heart failure, conduction system disease, valvular imcompetence and pericarditis. The development of such manifestations in a febrile compromised host with one or more predisposing factors should prompt consideration of disseminated mucormycosis in the differential diagnosis and initiation of appropriate diagnostic and therapeutic strategies.

Topics: mucormycosis , heart
Chest. 1992;101(6):1738-1739. doi:10.1378/chest.101.6.1738
Abstract
Chest. 1992;101(6):1740-1741. doi:10.1378/chest.101.6.1740
Abstract
Chest. 1992;101(6):1737a. doi:10.1378/chest.101.6.1737a
Abstract
Chest. 1992;101(6):1737b-1738. doi:10.1378/chest.101.6.1737b
Abstract
Chest. 1992;101(6):1739a. doi:10.1378/chest.101.6.1739a
Abstract
Topics: aortic arch
Chest. 1992;101(6):1739b-1740. doi:10.1378/chest.101.6.1739b
Abstract
Chest. 1992;101(6):1742a. doi:10.1378/chest.101.6.1742a
Abstract
Chest. 1992;101(6):1742b-1743. doi:10.1378/chest.101.6.1742b
Abstract
Chest. 1992;101(6):1743a-1744. doi:10.1378/chest.101.6.1743a
Abstract
Chest. 1992;101(6):1743b. doi:10.1378/chest.101.6.1743b
Abstract

Communications to the Editor

Chest. 1992;101(6):1741. doi:10.1378/chest.101.6.1741-a
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Abstract
Chest. 1992;101(6):1741. doi:10.1378/chest.101.6.1741-b
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Abstract
Chest. 1992;101(6):1741-1742. doi:10.1378/chest.101.6.1741-c
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Abstract
Chest. 1992;101(6):1744. doi:10.1378/chest.101.6.1744-a
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