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.     

Diagnosis and treatment of obstructive lung diseases

Obstructive pulmonary disease can be divided into bronchial asthma and chronic obstructive pulmonary disease. Using a questionnaire, we carried out a survey among doctors in Hordaland county in order to discover how they diagnosed and treated obstructive pulmonary disease. The response rate was 60%; 119 general practitioners and 48 hospital doctors. In spite of recommended guidelines, 20% of the doctors did not perform any kind of spirometry when diagnosing obstructive pulmonary disease. Spirometry after inhalation of bronchodilators or corticosteroids was performed by 29% of the doctors when diagnosing chronic obstructive pulmonary disease and by 43% when diagnosing asthma. 88% of the doctors who participated in our survey preferred to treat asthma with inhalation of beta-agonist or inhalation of corticosteroids, or both. This was in accordance with recommended guidelines. There was greater uncertainty amongst the doctors concerning the treating of chronic obstructive pulmonary disease, and the guidelines were followed to a lesser extent.     

Frequency dependence of total respiratory resistance in early airway disease

Patients who develop frequency dependence of lung compliance will theoretically have frequency dependence of pulmonary resistance. We investigated the ability of the simpler, noninvasive measurement of frequency dependence of total respiratory resistance to identify subjects with frequency dependence of compliance. Ten healthy nonsmokers, 14 asymptomatic smokers, and 6 patients with obstructive airway disease were studied. Frequency dependence of total respiratory resistance was determined by the superimposed oscillating airflow technique at 3 to 9 cycles per sec, and frequency dependence of lung compliance was determined by measurements at 10 to 80 breaths per min. Spirometry, airway resistance, closing volume, and closing capacity were also measured. Frequency dependence of lung compliance and total respiratory resistance were closely correlated (P less than 0.001, r = 0.82), but closing volume, closing capacity, spirometry, and airway resistance could not be used to identify subjects with abnormal frequency dependence of lung compliance. Measurements of frequency dependence of total respiratory resistance and lung compliance, total respiratory resistance at 3 cycles per sec, and closing volume minus expiratory reserve volume were able to distinguish significantly between the smokers and the nonsmokers, but spirometry, closing volume, closing capacity, and airway resistance could not. These data indicate that in asymptomatic smokers and subjects with obstructive airway disease, frequency dependence of lung compliance can be predicted from measurements of frequency dependence of total respiratory resistance. These two tests appear to have equivalent sensitivity and selectivity in detecting the uneven time constants in the airways of asymptomatic smokers.     

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

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

Lung cancer and chronic obstructive pulmonary disease

Spirometry can predict lung health and monitor disease and response to therapy. This noninvasive test can and should be done regularly by primary care providers. It can identify patients at risk for lung cancer as well as heart attack and stroke. Patients with abnormal spirometric findings can be warned that airflow obstruction has begun, which may provide the motivation to quit smoking. Abnormal spirometry measurements correlate with all-cause mortality. Approaches to early diagnosis of lung cancer continue to expand. For example, use of the new fluorescent bronchoscope can increase diagnostic accuracy in lung cancer by highlighting lesions that are malignant or likely to be malignant. For now, however, identification of airflow obstruction with spirometry and follow-up with sputum cytology provide the widest benefit.     

Certification and occupational health nursing. An historical perspective

BACKGROUND: The bronchodilator agent is an important drug for patients with chronic obstructive pulmonary disease. Methacholine is a popular bronchial provocative agent. Although the major acting site of bronchodilator, methacholine and upper respiratory tract infection (URI) has been evaluated in some studies, the sites are still in debate. This study investigated the exact major acting sites. METHODS: Thirty subjects participated in this study. Episodes of URI were identified by a questionnaire. Spirometry, bronchial provocative test with methacholine, and five minutes' inhalation of a mixture of helium and oxygen (HeO2) were done on day one. Spirometry, bronchodilator test, with five minutes' inhalation of HeO2 and expiratory flow-volume (F-V) curve were performed on another day. The change of pre- and post-HeO2 VEMax50 was calculated as delta VEMax50. The pre- and post-bronchodilator VEMax50 and delta VEMax50 differences were counted to decide the acting site of bronchodilator. After bronchial provocative test with methacholine, the volume of isoflow (VisoV) was estimated from pre- and post-HeO2 F-V curve to establish the acting site of methacholine. RESULTS: This study indicated that small airways are the major acting sites of bronchodilators, large airways are the major acting sites of methacholine and URI affects mainly large airways. Although airway hyperresponsiveness is more severe in subjects with positive methacholine response, the recovery of spirometry values is not significantly different between the methacholine-positive and -negative groups. CONCLUSIONS: The major acting sites of the bronchodilator, methacholine, and URI are the small, large and large airways, respectively. Bronchial hyperresponsiveness is not a cause of quick restoration of spirometry values in subjects with positive methacholine response.     

Amperometric lactate oxidase catheter for real-time lactate monitoring based on thin film technology

Electronic spirometry units were used to monitor lung transplantation recipients upon their return home. The data from 77 participants were used to develop methods to verify that the pulmonary function measurements, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), were reliable and valid. The standard deviation was calculated for the best daily effort on consecutive days of home spirometry. An acceptable upper limit for the standard deviation, as the measure of day-to-day reliability, was 0.20 for FVC and 0.15 for FEV1. Validity was determined by examining the mean difference (bias) between the spirometry done in the pulmonary function laboratory and the home monitoring results. The clinic values were slightly higher, with an average difference of 0.15 for FVC and 0.12 for FEV1. Therefore, the home spirometry measurements have a high degree of reliability and validity and can now be used for early detection of serious complications.     

Modulation of ipsilateral motor cortex in man during unimanual finger movements of different complexities

Amiodarone is an antiarrhythmic drug widely used to treat a variety of supraventricular and ventricular arrhythmias. However its drawback is a very slow elimination and very frequent adverse effects (thyroid, pulmonary, neurologic, ocular, dermatologic, hepatic disorders). We describe a patient who developed a pseudoalcoholic liver disease and a cirrhosis after use of Amiodarone for a long period of time.     

Preoperative pulmonary evaluation of the thoracic surgical patient

A test designed to separate those undergoing thoracic surgery without complications and those with complications must be both highly specific and sensitive. Clearly, the difference between patients at opposite ends of the population curves is easy to identify. Spirometry can be helpful for screening, although it is not a very discriminating test. If patients fall in the overlap region between the populations, however, it is impossible to discern the risks with any certainty using low-yield tests. A test with higher sensitivity, specificity, and predictive values is necessary to ascertain such marginal differences. With this kind of analysis at hand, preoperative testing can be divided into three predictive value groups. Calculating the predictive value of each preoperative test can provide a comparative measure of usefulness of discriminative power (Table 1). In this way, spirometry, blood gas analysis, and stair climbing tolerance are shown to be poor predictors of outcome. An intermediate predictive value can be achieved using diffusion capacity, exercise-induced decreases in O2 saturation, and exercise PVR. High predictive value can be accomplished with combination indexes (PPP, possibly PRQ), measurement of VO2 at 40 watts of exercise, or VO2max. Logic dictates a step-wise preoperative evaluation using prediction value analysis (Fig.4). A flow decision chart for the preoperative evaluation of patients for pulmonary resection begins with exercise oximetry, spirometry, and blood gas analysis as general screening tests to separate those patients at minimal or no risks for complications from those patients that require further evaluation. Functional indexes (PPP, PRQ) or exercise testing can aid further in the selection of those patients in whom a nonsurgical option should be considered. Flow decision chart for the preoperative evaluation of patients for pulmonary resection should continue to evolve as new information about outcome studies is gathered. Examination of outcome data will provide us with reduction of the size of the nonoperable population, so that we can deny only those patients who truly pose a prohibitive risk.     

Cerebral abscess as a complication of chronic otitis media

BACKGROUND: Airways inflammation is a feature of chronic obstructive pulmonary disease (COPD), but the role of corticosteroids in the management of clinically stable patients has yet to be established. A randomised controlled study was carried out to investigate the effect of high dose inhaled beclomethasone dipropionate (BDP) administered for two months to patients with stable, smoking related COPD. Sputum induction was used to evaluate bronchial inflammation response. METHODS: 34 patients (20 men and 14 women) were examined on three separate occasions. At the initial clinical assessment (visit 0), spirometry and blood gas analysis were performed. On visit 1 (within one week of visit 0) sputum induction was performed and each patient was randomised to receive either BDP 500 micrograms three times daily (treated group) or nothing (control group). After two months (visit 2), all patients underwent repeat clinical assessment, spirometry, and sputum induction. RESULTS: There were no differences in sputum cell counts between the groups at baseline. After two months of treatment, induced sputum samples from patients in the treated group showed a reduction in both neutrophils (-27%) and total cells (-42%) with respect to baseline, while the control group did not (neutrophils +9%, total cells +7%). Macrophages increased in the treated group but not in the control group. The mean final value of sputum neutrophils was 52% in the treated group and 73.3% in the control group (95% confidence interval (CI) -27.2 to -15.4). The mean final value of sputum macrophages was 35.8% in treated group and 19.3% in control group (95% CI 10.3 to 22.8). The differences between the treated and control groups for neutrophils (-21.3%), macrophages (+16.5%), and total cells (-65%) were significant. Spirometry and blood gas data did not change from baseline in either patient group. CONCLUSIONS: A two month course of treatment with high dose inhaled BDP reduces significantly neutrophil cell counts in patients with clinically stable, smoking related COPD. Further studies on the effectiveness of inhaled steroids in COPD are needed to confirm the clinical importance of this observation.     

Prevention of respiratory complications after abdominal surgery

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.     

Effects of psychological status on external respiration in patients operated for nonspecific lung diseases

Psychological tests and spirometry were used in examination of 39 patients operated on for severe chronic nonspecific pulmonary diseases. It was found that external respiration function was impaired more in emotionally strained subjects. Improvement of the external respiration coincided with diminution of hypochondria, positive changes in psychological status as a whole.     

Compliance with the "recommendations SEPAR" on spirometry

The objective of this study was to assess Spanish performance of spirometry and to determine the extent to which practice is in accordance with the 1985 SEPAR recommendations. To that end we formulated a questionnaire with 31 items in two sections, 10 covering basic aspects of compliance with necessary techniques and 21 general questions. The questionnaire was sent to all SEPAR members. One hundred eight responses were received. The results show that the typical spirometric measurement was forced expiration without a bronchodilator test by way of a pneumotacograph, with simultaneous representation of the flow/volume curve. Calibration, when performed, is done daily with a 3 1 syringe and atmospheric data are checked. Spirometric measurements are usually obtained by a registered nurse, who also collects anthropometric data directly from the patient. The patient is usually seated with the nose occluded. At least three and at most eight satisfactory readings are obtained. The criteria for starting and ending the maneuver and the reference values used are those recommended by SEPAR. The equipment is washed weekly with soap and water; calibrations and equipment incidences are not recorded. The level of compliance with 1985 SEPAR norms for forced spirometry is adequate with respect to some technical equipment questions but deficient on basic procedure and quality control.     

钢铁企业油脂优化整合初探

针对钢铁企业设备种类众多导致的油脂选型困难甚至供油出错等问题,通过制定润滑油脂准入、管理和报废标准,实施国产化替代,归并润滑油脂品种,强化设备润滑管理等方法,对钢铁企业设备用油进行优化整合初探。润滑油脂的优化整合,对钢铁企业正确选用油脂、降低采购成本、提升润滑管理水平和实现降本增效等具有重要的意义。     

Diagnosing and monitoring the clinical course of chronic obstructive pulmonary disease

COPD is an extremely common, chronic disorder characterized by a reduction in airflow after the administration of an inhaled bronchodilator as measured by the FEV1. The diagnosis is suspected in patients with a history of several decades of cigarette smoking who present with nonspecific respiratory symptoms. The diagnosis is established by simple forced expiratory spirometry. Baseline evaluation usually includes a chest radiograph and some assessment of functional capacity, either by history or with some form of exercise testing. In patients whose initial FEV1 is more severely reduced or who have significant dyspnea, an arterial blood gas is indicated at baseline. Dyspnea, hypoxemia, or hypercarbia that is out of proportion to the measured FEV1, at either presentation or follow-up, should prompt a thorough evaluation for complicating conditions. There are important roles in health care delivery and chronic disease management strategies for RCPs, primary care providers, and specialty trained pulmonary physicians. The need for repeated, extensive, or expensive testing will be largely driven by patients symptoms but disease monitoring with periodic assessments of dyspnea, functional capacity, and spirometry can be performed without great expense.     

Relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance in private practice.

Consumer satisfaction is widely used as an indicator of treatment quality; however, recent research in public clinics has found very little relationship between satisfaction and problem change. No research on private practice satisfaction has been reported. The current study compared satisfaction with a variety of outcome measures for 93 adult private practice clients and found no significant relationships. Satisfaction is inappropriately construed as an outcome measure and may be of more limited value than widely held. Quality assurance standards should rely more on assessments of adjustment, perhaps using brief measures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Caring for AIDS patients at home--requirements for development of the concept

Exercise tolerance in chronic obstructive pulmonary disease (COPD) patients treated with oral aminophylline may be different from those treated with high-dose inhaled ipratropium bromide. The purpose of this study was to compare the effects of therapeutic doses of oral aminophylline with high-dose ipratropium bromide on spirometry and exercise tolerance. The study was conducted on three consecutive days in a double-blind, randomized, crossover fashion. Baseline studies obtained on each study day included vital signs, simple spirometry and a symptom-limited maximal cardiopulmonary stress test, after which patients received one of the following treatments on each day: Treatment 1, inhaled ipratropium (total dose of 144 micrograms) with placebo tablets; Treatment 2, inhaled placebo with oral aminophylline (400 mg); Treatment 3, inhaled placebo and placebo tablets. Simple spirometry was repeated at 60 and 120 min after baseline. Vital signs and cardiopulmonary stress testing was repeated at 120 min. Eighteen patients were enrolled in the study, and 17 of these completed the study. There was a significant (P < 0.05) increase in both forced expiratory volume in 1 s (FEV1), from 0.75 (0.21) to 0.92 (0.3), and forced vital capacity (FVC), from 1.8 (0.79) to 2.11 (0.84), with high-dose ipratropium despite prior beta-agonist therapy. Lack of improvement in exercise capacity was noted with ipratropium despite improvement in spirometry. These results suggest that elderly patients with severe COPD may have exercise limitation that is not directly dependent on severity of airflow obstruction. Ipratropium bromide and aminophylline demonstrated no acute effects on exercise capacity.     

Graded functional activation in the visuospatial system with the amount of task demand

Immunocompromised hosts have defects in their immune system that make them at risk of developing a variety of infections. In addition, these persons may develop a wide variety of noninfectious disease processes that involve the lung. These disorders may be caused by the underlying disease process. This may be seen with the development of metastatic disease from the underlying neoplasm, or it may represent the development of a malignancy secondary to therapy, as is seen with posttransplant lymphoproliferative disease. The abnormalities may be a result of the therapy used to treat the patients, as is seen with radiation injury to the lung and drug toxicity. Pulmonary edema may occur and be from a wide variety of causes. All of these disease processes may simulate an infectious process and must be differentiated from infection to allow proper therapeutic intervention.     

Creation and growth of oxygen-converter steelmaking

Modern oxygen-converter steelmaking is a combination of a technology that has proven itself over many years and modern equipment that controls the steelmaking operation and protects the environment. When used together with out-of-furnace treatment units, this steelmaking method makes it possible to produce steel for high-technology applications in accordance with the most stringent existing standards on the cleanliness of the metal. The method is flexible, is characterized by extremely high productivity, and can be incorporated in a very wide range of manufacturing processes. As a high technology, oxygen-converter steelmaking will remain in demand for decades to come. __________ Translated from Metallurg, No. 1, pp. 64–67, January, 2007.     

The usefulness of clinical pulmonary examination in the diagnosis of bronchial obstruction

In order to evaluate the usefulness of physical examination of the chest in diagnosing bronchial obstruction, 11 doctors recorded their findings in 692 adult chest patients. Spirometry was carried out after the physical examination. Two categories of patients were selected; patients with known or suspected pulmonary disease (n = 209) and patients who had consulted their doctors for other reasons (n = 483). Bronchial obstruction defined as either FEV1 < 70% predicted or FEV1 < 70% of FVC, was found in 74 of the "pulmonary patients" and 55 of the "non-pulmonary" patients. In the group of patients with bronchial obstruction, a pathological or less certain sign of chest disorder was found in 91% of the "pulmonary" patients, and in 42% of the "non-pulmonary" patients (p < 0.000001). Strenuous respiration was registered in 41% of the "pulmonary" patients with bronchial obstruction, whereas sensitivity was only 2% in the other group. Where there were two or more pathological chest findings, the risk of bronchial obstruction occurring was 66% among the "pulmonary" patients, as opposed to 37% in the "non-pulmonary" group. Physical examination of the chest appeared to be very useful in the detection of bronchial obstruction in patients with pulmonary symptoms, but of limited value in screening for bronchial obstruction.