Diagnosis of asthma and chronic obstructive pulmonary disease in general practice

There may be an overlap between the clinical pictures of asthma and chronic obstructive pulmonary disease which hampers a clear distinction between the two diseases. Most symptoms presented by patients do not clearly belong exclusively to either asthma or chronic obstructive pulmonary disease. By the nature of their discipline and training, general practitioners focus mainly on symptoms presented, which do not give a decisive answer in the differential diagnosis between the two diseases. Therefore, general practitioners must rely on objective parameters, such as determining the presence and degree of reversibility of airway obstruction, diurnal peak flow variability, bronchial hyper-responsiveness and allergy. This paper puts forward a pragmatic, primary care definition of asthma and chronic obstructive pulmonary disease.     

Pulmonary hemodynamics and external respiratory function in patients with chronic obstructive lung diseases. The diagnostic value of complex radiologic study

A study made of the external respiration function and pulmonary hemodynamics in 43 patients with chronic obstructive pulmonary diseases by fluorography and tomography disclosed highly significant signs of impairement of the external respiration function and pulmonary hemodynamics at early stages in the course of these conditions' development. The above findings are confirmed by a series of non-invasive techniques of investigation, such as radiopulmonography, jugular phlebography, tetrapolar pulmonary rheoplethismography.     

On respiratory stimulation by aminophenazol in global insufficiency due to chronic-obstructive diseases of the lungs (author's transl)

For evaluation of a respiratory analeptic as supplementary therapy in global insufficiency blood gas analyses were performed on 19 patients under normal room air conditions as well as under oxygen breathing. It could be proved that with 2,4-diamino-5-phenylthiazol (aminophenazol; Daptazile) respiratory depression associated associated with chronic obstructive pulmonary diseases can be influenced and that here is statistically significant improvement of respiration. Effects of mechanical breathing and hyperventilatin are discussed -- basing on the present evaluation results they need not be expected. Side effects were not registered. With simultaneous and exhaustive application of all therapeutic means for the remedy of pulmonary obstruction amiphenazol is recommended for use in cases of pulmonary hypoventilation and primary central respiratory depression.     

Chronic alveolar hypoventilation: a review for the clinician

Chronic alveolar hypoventilation may present in an insidious fashion with nonspecific manifestations. The clinician should be aware of the potential for developing this condition in patients with certain thoracic and systemic diseases. Once chronic alveolar hypoventilation is confirmed with arterial blood gas analysis, a systematic evaluation can often point to the underlying etiology. As sleep in affected individuals is often associated with marked worsening of gas exchange and may also contribute to worsening daytime cardiopulmonary dysfunction, polysomnography is often indicated to determine the severity of nocturnal aberrations and to look for coexistent obstructive sleep apnea. Therapy of chronic alveolar hypoventilation often focuses on elimination of the nocturnal deterioration in gas exchange, and recent applications of noninvasive positive pressure ventilation during sleep have proven useful in the management of individuals with obesity-hypoventilation syndrome, restrictive thoracic disorders, neuromuscular diseases and central causes for hypoventilation. It is unclear whether wide-spread application of nocturnal ventilatory support to patients with chronic ventilatory failure due to chronic obstructive pulmonary disease is of long-term benefit.     

Occlusion pressure responses in asthma and chronic obstructive pulmonary disease

During CO2 rebreathing we measured ventilation and the pressure generated during the first 0.1 sec of inspiratory effort against a closed airway (P 0.1) in 12 asthmatics during acute exacerbation, 10 normal subjects, and 10 patients with chronic obstructive pulmonary disease. In normal subjects, the ventilatory responst to CO2 correlated with the P 0.1 response measured as delta In P 0.1. Patients with chronic obstructive pulmonary disease showed depressed responses to CO2 in terms of both ventilation and deltaIn P0.1. However, P 0.1 values in the patients with chronic obstructive pulmonary disease were greater than those of the normal subjects when they were compared at an alveolar PCO2 of 60 mm Hg. Asthmatics' responses to CO2 were similar to those of patients with chronic obstructive pulmonary disease. When measured at an alveolar PCO2 of 60 mm Hg, asthmatics' P 0.1 values were greater than those of both normal subjects and patients with chronic obstructive pulmonary disease. As the asthmatics' airway obstruction decreased so did their P 0.1. The asthmatics, and to a lesser extent the patients with chronic obstructive pulmonary disease, demonstrated increased inspiratory muscle activity that could not be explained on the basis of chemical drive or alterations in functional residual capacity. In the case of the asthmatics it was possible that the increased inspiratory muscle activity was a response to airway obstruction.     

Redox regulation of cellular signaling

The authors are presenting the first cases in Romania in which volumetric ventilators Monnal D type were used for external ventilatory assistance on nasal mask of the chronic obstructive pulmonary diseases in exacerbation. The paper reviews the problems issued during the use of ventilators in 5 chronic patients, with numerous previous admittances in our clinic, as well as the latest news in the field of modern therapy of COPD.     

Chronic obstructive pulmonary disease and '150 years of blowing'

Spirometry is now an established and important aspect of investigation of many lung diseases. This article considers the history of spirometry, how we come to use the current indices of dynamic lung function, and the role of spirometry in the management of patients with chronic obstructive pulmonary disease.     

Subxiophoyd echocardiography: pulmonary artery or aorta (author's transl)

Six patients with chronic obstructive pulmonary diseases, have been examinated by subxiophoyd echocardiography associated with ultrasonic contrast of right heart. It is detected that the vessel placed behind anterior cavity is aorta. This is confirmed by study of calcific aortic stenosis too, where the calcifications allows sure localisation of the vessel. Main pulmonary artery, or its branches, is instead visible behind aorta.     

Chronic obstructive pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic Obstructive Pulmonary Disease Study Group

BACKGROUND: The American Thoracic Society recently recommended that chronic obstructive pulmonary disease be staged on the basis of the percentage of predicted FEV1. OBJECTIVE: To examine 1) the relation between the american Thoracic Society system for staging chronic obstructive pulmonary disease and health-related quality of life and 2) the effect of self-reported comorbid conditions on health-related quality of life. DESIGN: Cross-sectional study. SETTING: Outpatient clinics of respiratory departments of four hospitals and one primary health care center in spain. PATIENTS: 321 consecutive male patients with chronic obstructive pulmonary disease. MEASUREMENTS: Functional respiratory impairment, FEV1, respiratory symptoms, and health-related quality of life. Respiratory symptoms and health-related quality of life were measured by using the Spanish version of the St. George's Respiratory Questionnaire and the Nottingham Health Profile. RESULTS: Patient scores on the St. George's Respiratory Questionnaire were moderately to strongly associated with disease staging (r = 0.27 to 0.51). Compared with reference values, values for health-related quality of life for patients with stage I disease were substantially higher on the St. George's Respiratory Questionnaire (6 and 34; p < 0.001) and values for impairment were significantly greater in stage 1 patients with comorbid conditions (19 and 36; P = 0.001). At least one concomitant chronic condition was found in 84% of study patients. Comorbid conditions only partly influenced the observed pattern of deterioration of health-related quality of life with worsening stages of disease. CONCLUSION: Staging criteria for chronic obstructive pulmonary disease based on percentage of predicted FEV1 separated groups of patients with varying degrees of impairment in health-related quality of life. Contrary to expectations, even patients with mild disease showed substantially compromised health-related quality of life. Comorbid conditions influenced the relation between chronic obstructive pulmonary disease and health-related quality of life.     

Relevance of width measurements of the right pulmonary artery descending branch for detection of pulmonary hypertension in chronic obstructive lung diseases (author's transl)

363 patients with chronic obstructive lung diseases were examined regarding the relation between pulmonary hypertension and width of the right descending branch of the pulmonary artery (RDB). There was found a high significant correlation between mean pulmonary artery pressure at rest and diameter of the RDB. The width of RDB was not so close correlated with pulmonary artery pressure during exercise. If the diameter of the RDB was 19 mm and more, a manifest pulmonary hypertension was stated nearly always. Missing this radiological sign doesn't exclude pulmonary hypertension. The method will be useful for screening a risk group "pulmonary hypertension". All cases selected by this method aught to be examined by means of right heart catheterization with the floating technic.     

Clinical effects of low-dose and long-term erythromycin in diffuse panbronchiolitis with chronic respiratory failure

We studied the effects of erythromycin (EM) in diffuse panbronchiolitis (DPB) with chronic respiratory failure. Seventeen patients with DPB or sinobronchial syndrome receiving home oxygen therapy (HOT) were treated with EM of 400-600 mg/day for twelve months. Five patients discontinued HOT, and hypoxemia was improved in five other patients. Clinical effects were evident at one month after the start of EM administration, and a stable state was achieved after six months of EM therapy. FEV1 was significantly increased in pulmonary function tests. Factors which influenced the effects of EM included the period between onset of clinical symptoms and commencement of HOT and/or between commencement of HOT and administration of EM. EM was effective for patients with obstructive, but not constrictive impairment in pulmonary function tests. These findings indicate that EM is effective for DPB even in patients with chronic respiratory failure.     

Value and costs of pulmonary rehabilitation

Pulmonary rehabilitation (PR) is nowadays a recognized discipline for stabilisation and improvement of chronic pulmonary diseases. According to epidemiologic data the number of patients with chronic obstructive bronchitis and asthma is on the rise. Aim and components of a modern stationary PR-program are defined and benefit and costs discussed according to data from recent publications. Necessity of an individual, stepwise, multidisciplinary and holistic approach to physical and psychic symptoms based on an exact diagnostic workup is shown. Data from selected studies on benefits of PR such as reduced frequency and/or cost of hospitalisations, improved quality of life or reduced symptoms, improvement of pulmonary function and effects on mortality and working capacity are discussed. Since controlled studies are unavailable from Switzerland so far, data from American and European literature are used. In the most severe terminal stages of pulmonary failure individual complementary surgical measures have to be evaluated, i.e. volume-reducing surgery for emphysema or transplantation of the lung. The peri- and postoperative risks and arising costs have to be weighted against the expected improvement of pulmonary function and quality of life by exhaustive conservative measures.     

12th Pneumology Colloquium of the Lucerne Montana High Altitude Clinic

Asthma bronchiale is a very common disease in our western countries. According to the SAPALDIA study (Swiss study on air pollution and lung diseases in adults) 7% of the Swiss population suffer from bronchial asthma or have complained once or several times about asthmatic symptoms. Roughly 3% of the Swiss suffer from chronic obstructive pulmonary disease. The standard treatment for both these conditions of bronchi and bronchioles is inhalation therapy. The enormous advantages of inhalation therapy, i.e. direct action of the drugs at the site of disease and the good acceptance by patients are opposed by the difficulties for correct inhalation. All devices, pressure nebulizers, powder delivery systems or aerosol dispensers have to be explained in depth to patients to achieve optimal results. Teaching of inhalation technique is the mission of the physician, in hospitals also of physiotherapists and nursing staff. Patients with chronic pulmonary diseases are cared for by the lung leagues whose collaborators are carefully trained for treating, instructing and surveilling patients.     

Pulmonary thromboembolism

Pulmonary embolism (PE) is a serious complication of chronic obstructive pulmonary disease (COPD). Retrospective studies on patients with COPD treated in the intensive care unit (ICU) were performed to determine: 1) the frequency of PE; 2) the clinical course of PE in cases of COPD in the ICU; and 3) the frequency of PE as a cause of death in the studied group. The frequency of PE was 10.9% in COPD patients. In the group analysed, clinical presentation of PE was characterized by acute severe, life-threatening complications leading to death in 86.7% of cases. PE was the most frequent cause of death (40.6%) in COPD patients in the ICU. The results of treatment of pulmonary embolism in chronic obstructive pulmonary disease are poor and mortality in this group of patients is very high. We believe that improvement of management can be achieved by antithromboembolic prophylaxis, which should be instituted as soon as possible in all patients with chronic obstructive pulmonary disease in the intensive care unit.     

Pulmonary manifestations of Sj?gren's syndrome

Sj?gren's syndrome is one of the most common systemic rheumatic diseases. Pulmonary disease is prevalent in Sj?gren's syndrome; respiratory manifestations include chronic cough, obstructive airways disease, pulmonary lymphoma, and interstitial lung disease that may progress to severe pulmonary fibrosis.     

Analgesic response in offspring of crosses between heroin delta (Swiss Webster) and mu (ICR) responding mice

To indirectly test the hypothesis whether serotonin (5-HT) might have a role in the increase in pulmonary vascular resistance, we evaluated the haemodynamic and gas exchange response of intravenous ketanserin (K), a 5-HT receptor inhibitor, in eight severe but stable patients with chronic obstructive pulmonary disease with secondary pulmonary hypertension (mean pulmonary artery pressure (Ppa) 30.3 +/- 7.3 mmHg). Measurements were done at baseline, after oxygen breathing (2 L.min-1), K bolus (6-15 mg) and finally during oxygen breathing (2 L.min-1) added to K infusion (3-6 mg.h-1). K bolus induced a significant reduction of mean Ppa (p < 0.05), mean systemic arterial pressure (p < 0.01) and total systemic resistance (p < 0.01). Cardiac index (+7%), oxygen delivery (+7%) and pulmonary vascular resistance (magnitude of the reduction: -12%) did not change significantly. When oxygen was added to K infusion, the cardiac index significantly dropped when compared to K bolus (p < 0.05), but oxygen delivery remained stable because of the resulting increase in arterial oxygen concentration; against baseline, the mean Ppa showed the same magnitude of reduction as with oxygen breathing or K bolus alone (p < 0.05). Ventilation and gas exchange were not significantly influenced by K bolus. When we individually analysed the changes of pulmonary vascular resistances by plotting the driving pressure through the pulmonary circulation against the cardiac output, we observed that an active vasodilating effect on the pulmonary circulation occurred with K in only one patient, while in three other patients there was rather a recruitment effect of the pulmonary vessels due to the systemic effects of the drug. In conclusion, this study of a small number of patients with severe chronic obstructive pulmonary disease associated with pulmonary hypertension shows that the parenterally given serotonin antagonist ketanserin predominantly affects the systemic circulation. Our results do not support the hypothesis that in stable chronic obstructive pulmonary disease patients with pulmonary hypertension, serotonin might have a role in the increase of pulmonary vascular tone.     

Effects of support pressure ventilation with facial mask in patients with chronic respiratory failure in acute decompensation

BACKGROUND: In previous nonrandomized studies the efficacy of ventilation with back up pressure with face mask (BUPM) in the treatment of patients with chronic obstructive pulmonary disease (COPD) in acute decompensation has been demonstrated. This study analyzes the acute effects and the clinical efficacy of BUPM in a group of patients with COPD in acute respiratory failure comparing the same with conventional therapy (CONV). METHODS: A prospective randomized study including patients with COPD in acute decompensation was carried out comparing treatment with BUPM (n = 9) with CONV treatment (n = 9). Back up pressure was fixed at 20 cmH2O. Acute gasometric effects were analyzed as well as the need for intratracheal intubation, mortality and hospital stay. RESULTS: No clinical or gasometric differences were found between either group of patients upon admission. Only the patients of the BUPM group presented a significant improvement from gaseous exchange and respiratory frequency from the first hour of treatment. Three of the nine patients (33%) of the BUPM group and nine of the CONV group of patients (100%) required intubation and mechanical ventilation (p = 0.001). CONCLUSIONS: Back up pressure face mask is the technique of choice in patients with chronic obstructive pulmonary disease in acute decompensation given that this technique leads to a rapid and significant improvement of gaseous exchange and avoids the need for intubation and mechanical ventilation in most of these patients.     

Multidisciplinary treatment of chronic pulmonary insufficiency. 4. The influence of intrathoracic pressure variations on increases in pulmonary vascular pressure during exercise in patients with chronic obstructive pulmonary disease

In the present era of direct monitoring of pressure in patients with chronic obstructive pulmonary disease (COPD), an appreciation of all factors that may influence the observed pulmonary vascular pressures is essential. Our study examines the impact of respiratory variations in intrathoracic pressure on the recorded pulmonary vascular pressures in 28 patients with COPD. Althouth pulmonary hypertension was present in only nine subjects at rest, all had an abnormal increase in the mean pulmonary arterial pressure during supine exercise. In 15 subjects, this abnormal response was, in part, related to an increase in pulmonary arterial wedge pressure to 15 mm Hg or more. The increase in pulmonary arterial wedge pressure was directly related to the amplitude of the peak-to-peak respiratory variation of such wedge pressure. This variation correlated with the specific airway resistance but was not related to the arterial oxygen pressure or pulmonary vascular resistance. These findings indicate the important influence of exaggerated respiratory effort on the measurement of pulmonary arterial wedge pressure and mean pulmonary arterial pressure in patients with chronic obstructive pulmonary disease.     

DNA reactions, mutagenic action and stealth properties of polycyclic aromatic hydrocarbon carcinogens (review)

OBJECTIVE: To present a critical review and meta-analysis of studies evaluating the long-term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease (COPD). DATA SOURCES: A database of articles published over the last 45 years, compiled by using medical subject heading key words pulmonary, obstructive, rehabilitation, and exercise. Articles not written in English, Dutch, or German and abstracts were excluded. STUDY SELECTION: Selected studies (1) evaluated the effects of pulmonary rehabilitation, (2) included patients with asthma or COPD older than 18 years, (3) evaluated outcome measures of exercise capacity or health related quality of life (HRQL), and (4) included a control condition lacking exercise training. DATA EXTRACTION: Independent extraction by two reviewers. DATA SYNTHESIS: For each outcome, summary effects were computed by pooling standardized mean differences as well as raw mean differences. Significant improvements were found for all outcomes (p < .001). Sensitivity analyses for methodological quality of the selected studies did not change summary effect sizes. Effect sizes were significantly heterogeneous for the outcome endurance time (p < .0001). Pooling raw mean differences revealed overall effects in 6-minute walking distance (49+/-26 m) and all 4 dimensions of the chronic respiratory questionnaire (range, 0.5+/-0.3 to 0.8+/-0.3 points), indicating substantial improvements in these outcomes. Significant summary effect sizes were found up to 9 months after finishing rehabilitation for maximal exercise capacity (p < .003) and 6-minute walking distance (p < .005). CONCLUSIONS: Patients with asthma and COPD benefit from pulmonary rehabilitation.