Search

Objective: To evaluate arterial lactate levels during treatment of acute severe asthma (ASA) and the prognostic value of arterial hyperlactatemia in ASA., Design: Prospective study., Setting: A respiratory intensive care unit (ICU) of a university hospital., Patients: 29 consecutive patients admitted to the ICU for ASA not intubated on admission and with a peak expiratory flow (PEF) < 150 l/min or an arterial carbondioxide tension (PaCO2) > 40 mm Hg. All patients received standardized treatment during the first 24 h including i.v. and nebulized salbutamol, i.v. theophylline, and dexamethasone., Measurements and Results: Arterial lactate levels were serially measured by an enzymatic method during the first 24 h following admission. On admission, the mean arterial lactate level was 3.1 +/- 0.38 mmol/l (range 1.1-10.4); 17 patients (59%) had arterial hyperlactatemia with a lactate level > 2 mmol/l. No difference was found in lactate levels between patients with progressively worsening asthma and those with an acute onset of severe asthma. No correlation was found between arterial lactate levels on admission, on the one hand, and respiratory rate (RR), heart rate, PEF, pH, PaCO2, arterial oxygen tension, potassium, phosphorus, creatine kinase, or transaminase values on admission, on the other hand. All patients developed an important but transient increase in arterial lactate levels during treatment, with a peak at 7.72 +/- 0.46 mmol/l and a mean elevation of 4.62 +/- 0.45 mmol/l (range 0.4-12.1), from the initial admission value contrasting with a significant clinical improvement assessed by RR, PEF, and arterial blood gas parameters., Conclusion: This study suggests that, in ASA, arterial hyperlactatemia is frequently present on admission to the ICU. Delayed hyperlactatemia is a constant finding during treatment of ASA. Initial or delayed hyperlactatemia seems of no prognostic value because none of the patients required mechanical ventilation. The effects of therapy for acute asthma on lactate metabolism still need to be studied.

Spiral CT angiography was performed in a patient suspected of having pulmonary embolism. The right pulmonary system was normal. The left arterial system was small but patent. The left upper lobe was small and hyperlucent. The left lower lobe was collapsed and contained bronchiectasis. The bronchi were patent. High resolution CT in inspiration and expiration confirmed air trapping in the left upper lobe. A diagnosis of Swyer-James syndrome of the left upper lobe was made.

Malnutrition in patients with chronic obstructive pulmonary disease (COPD) is classically ascribed to an increased resting energy expenditure (REE) secondary to high cost of breathing. However, malnutrition correlates only weakly with the severity of respiratory dysfunction, which suggests other mechanisms. The aim of the present study was to determine the possible role of diet-induced thermogenesis (DIT). Therefore, we evaluated the relationship between DIT and nutritional status, in particular fat-free mass (FFM) estimated by bioelectrical impedance analysis in 26 patients with stable COPD (mean FEV1 +/- SEM = 36.5 +/- 3.8% of predicted). Ten patients were undernourished (weight < 90% of ideal body weight [IBW] and/or FFM < 69% of IBW), and 16 were normally nourished. Diet-induced thermogenesis was determined by comparing postprandial energy expenditure and REE, the latter being measured after an overnight fast and the former over 4 h after a mixed test meal of 0.4 times REE load. No statistical difference in DIT was found between undernourished and eutrophic patients. There was no relationship between DIT and nutritional or functional parameters, notably FFM. These results suggest that malnutrition is not a consequence of an increased DIT.

The diagnostic value of Cyfra 21-1 in non-small lung cancer (NSCLC) has been established, but few studies have focused on its prognostic value. The aim of this study was to compare that of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, CA 125, neuron-specific enolase and squamous cell carcinoma antigen. 116 patients with unresectable (n = 88) or resectable (n = 28) NSCLC were prospectively monitored from diagnosis, for a median of 14.4 months. All patients underwent tumour-marker determinations before treatment, then every 3 months. Their diagnostic value was studied using ROC (receiver operating characteristic) curves, based on control measure in 23 patients with benign lung diseases. The prognostic analysis was based on overall survival as the main endpoint. The diagnostic value of Cyfra 21-1 was confirmed, with a sensitivity of 54% and a specificity of 96% at a cut-off value of 3.3 ng/ml. At diagnosis, in the 88 non-surgical NSCLC, besides the presence of metastases (P = 0.017), Cyfra 21-1 (P = 0.017) and CA 125 (P = 0.03) were related to outcome. Elevated levels of Cyfra 21-1 at any time during the disease course was selected by multivariate analysis as additional predictors of poor survival.

Background: The objective of this prospective study was to assess in 96 patients with resected nonsmall cell lung carcinoma (NSCLC) the prevalence of both blood and lymphatic vessel invasion (BVI and LVI) according to stage, as well as their prognostic value for disease free and overall survival., Methods: BVI and LVI were evaluated by hematoxylin and eosin stains on surgical specimens after resection. Associations among variables were tested by Fisher's exact test or the chi-square test; prognostic values on time-failure data were analyzed by the log rank test and the multivariate Cox model., Results: BVI was present in 52% of NSCLC cases and LVI in 59%. Venous but not arterial vascular invasion correlated with the T factor and pTNM, whereas LVI correlated with the N factor and pTNM. In univariate analysis, LVI but not BVI was associated with a short disease free interval (P = 0.0007) and poor survival (P = 0.0001). The estimated relative risk of death in patients with LVI was 3.2 compared with patients without LVI. In multivariate analysis, LVI and pTNM were additional predictors for poor disease free and overall survival. In this series, BVI had no prognostic value., Conclusions: The prevalence of BVI and LVI appeared high in patients with NSCLC, especially those with advanced pTNM stages. LVI was predictive of poor outcome, both time to recurrence and death.

Objective: To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA)., Design: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period., Setting: University teaching ICU and pneumonology department., Patients: 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age., Measurement and Results: Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value., Conclusion: BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

We report a case of Mycobacterium kansasii endobronchial infection presenting as a tumor obstructing 2 segmental bronchi in a patient with the acquired immune deficiency syndrome. Biopsies of the lesions revealed granuloma with acid-fast organisms. Culture grew M. kansasii. To our knowledge, this is the first case of M. Kansasii infection presenting with endobronchial mass.

We report a case of severe primary pulmonary hypertension occurring in an HIV+ patient in whom lung biopsy and post-mortem examination were consistent with thrombotic pulmonary arteriopathy. To the best of our knowledge, this histological pattern has not been previously reported in HIV+ patients with primary pulmonary hypertension.

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p < 0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] < 80 percent pred) in 68 percent of patients, and markedly depleted (TSF < 60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (< 60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (< 100 mg/L), retinol-binding-protein (< 20 mg/L), and albumin (< 20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

A case of exogenous lipoid pneumonia was documented by computed tomography and magnetic resonance imaging. Although strongly suggesting the presence of fat on T1 weighted images, magnetic resonance does not produce images specific for this condition. Computed tomography is the best imaging modality for its diagnosis.

Metoclopramide was administered by continuous infusion to two groups each of 14 patients on chemotherapy, randomized to receive either doses adjusted to individual pharmacokinetic parameters or doses adjusted as usual to body weight. The mean plasma concentration at the end of the infusion in the adjusted group was 1.01 mg.l-1, close to that aimed for (1.20 mg.l-1). It was significantly different from that in the other group. v 0.54 mg.l-1. Antiemetic efficacy, defined as less than or equal to 2 emetic events in the 24 h following cisplatin, was similar in both groups (being found in 12/14 (86%) and 10/14 patients (71%), respectively). Analysis of the cumulative percentage of responders according to plasma concentration showed a clear plasma concentration-effect relationship. Routine MCP pharmacokinetic dosage adjustment is not indicated, but this therapeutic approach can be used to optimize antiemetic therapy in poor responder patients.

A patient with chronic obstructive pulmonary disease and acute respiratory failure developed grand mal seizures in the hours following onset of mechanical ventilation. These seizures were associated with an acute increase in arterial pH and were related to the occurrence of acute severe hypophosphataemia associated with recovery from respiratory acidosis.

A case is reported of theophylline intoxication due to a dramatic decrease in theophylline clearance following concomitant administration of viloxazine.

We report a case of a 31-year-old male with primary pneumococcal pericarditis. Severe acute constrictive pericarditis developed within a month of the onset of the illness in spite of adequate antibiotic therapy and pericardial drainage.

In patients with acquired or congenital heart diseases, the systolic pulmonary artery pressure (PAPs) can be predicted using continuous-wave Doppler ultrasound (CWD) measurement of the peak velocity of a tricuspid regurgitation (TR) jet. The aim of this study was to determine whether CWD could be used to accurately estimate PAP in patients with chronic obstructive pulmonary disease (COPD). In 41 patients with stable COPD, we prospectively performed CWD and right heart catheterization. The mean value of PAPs for the entire group was 38.5 +/- 14.9 mm Hg. Pulmonary arterial hypertension (PAPs greater than or equal to 35 mm Hg) occurred in 51 percent (21/41) of patients. Doppler estimation of PAP was impossible in 34 percent (14/41) because of poor signal quality (n = 3), absence of Doppler-detected TR (n = 8), and inadequate TR Doppler signal (n = 3). The PAP could be estimated in 66 percent (27/41) of patients. A statistically significant correlation was found between the Doppler-estimated PAP and the catheter-measured PAPs (r = 0.65; p less than 0.001; SEE = 9 mm Hg). Therefore, CWD appears to be useful for the noninvasive estimation of PAP in patients with COPD. However, this method is associated with two limitations: (1) the high percentage of patients in whom the PAP cannot be estimated by CWD, mainly because of the absence of Doppler-detected TR, and (2) the high value of the standard error of the estimate. The combination of CWD with other Doppler methods should increase the feasibility and accuracy of Doppler echography for the prediction of PAP in patients with COPD.

The authors studied the ultrastructural morphology of the lung in one case of Bourneville's tuberous sclerosis with pulmonary involvement. The observations in this report are similar to those previously reported in pulmonary lymphangioleiomyomatosis and further emphasize the striking resemblance between the two diseases.

A case of lymphomatoid granulomatosis arising in a patient with a long history of dysimmunity is reported. The autopsy reviewed the final evolution into a high grade malignant lymphoma with IgM K immunoglobulin production and discovered in deep lymph nodes modifications similar to angio-immunoblastic lymphadenopathy.

Transbronchial biopsy is the technique of choice for obtaining tissue for histological diagnosis in many pulmonary disorders. The procedure has usually been carried out as an inpatient procedure with the use of fluoroscopy, though this policy has recently been questioned. This report concerns a five year experience of 174 transbronchial biopsies performed without fluoroscopy as an outpatient procedure in patients with interstitial lung disease or a suspicion of sarcoidosis. Chest radiography was carried out only if the patient developed symptoms. No major complications were encountered and the overall complication rate was low. Pneumothorax occurred in six patients (3.4%), only one of whom required intercostal intubation, and bleeding of more than 30 ml occurred in two patients. Histological diagnosis was obtained in 154 patients (88%). In the experience of this group transbronchial biopsy has been safe when carried out as an outpatient procedure without fluoroscopic guidance.

A canary breeder with Waldenström's macroglobulinemia developed a pulmonary disease related to an interstitial infiltration by malignant B cells secreting a monoclonal IgM K. The serum monoclonal IgM was shown to possess an antibody activity to some canary's droppings antigen. This finding may help elucidate the natural course of lymphoid malignancies and the pathogenesis of rare visceral localizations.

Computed tomography was used to evaluate mediastinal lymph nodes in 97 patients with nonsmall cell lung cancer. All patients had thorough surgical-pathological determination of mediastinal node status. Twenty-three patients were found to have metastatic lymph nodes. The usual lymphatic pathways of tumor spread into the mediastinum were defined using the node mapping scheme suggested by the American Thoracic Society. We considered mediastinal nodes abnormal when the short axis of the largest mediastinal node in the lymphatic drainage territory of the cancer was greater than or equal to 10 mm and the difference between this node and the largest node in the other territories is greater than 5 mm. The sensitivity was 78%, the specificity 99%, the positive predictive value 95%, the negative predictive value 94%, and the accuracy 94%. Comparing our method to those that used the size criterion alone, the number of false positives was reduced.

The aim of this study was to assess prospectively the variations of serum phosphorus concentration (P) after onset of mechanical ventilation (MV) in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory acidosis. In 14 COPD patients, we measured P, PaCO2, and pH, immediately before MV (H0), then one hour (H1), 4 (H4), 7 (H7), 12 (H12), and 24 h (H24) after starting MV. P at H0 was in or above the normal range in ten patients and below normal range in four patients. P decreased significantly (p less than .001) after MV at H1, H4, H7, H12, and H24. Hypophosphatemia was present in all patients after MV, but was severe (p less than .3 mmol/L) in only two patients. There was a significant correlation (r = .56 p less than .01) between the decrease of P and the increase of pH after MV. Hypophosphatemia was a constant and early finding after institution of MV in COPD patients and was presumably related to an intracellular shift of P secondary to the correction of respiratory acidosis.

Pulsed Doppler echocardiography of the inferior vena cava is an accurate method for the diagnosis of tricuspid regurgitation and impaired right ventricular compliance, two features of pulmonary hypertension. The purpose of this study was to assess the value of Doppler echocardiography of the inferior vena cava for the detection of pulmonary arterial hypertension in patients with chronic obstructive lung disease. Pulse Doppler echocardiography of the inferior vena cava and right heart catheterisation were performed in 29 patients with severe chronic obstructive lung disease. The mean pulmonary arterial pressure was 27 (10) mm Hg for the entire group; 62% of patients (18/29) had pulmonary arterial hypertension (mean pulmonary arterial pressure greater than 20 mm Hg). An adequate Doppler signal could be obtained in 25 of the 29 patients (86%). Pulsed Doppler echocardiography of the inferior vena cava gave normal results in 10 patients and disclosed tricuspid regurgitation in seven patients, impaired right ventricular compliance in seven patients, and both of these abnormalities in one patient. An abnormal Doppler echocardiogram of the inferior vena cava (tricuspid regurgitation or impaired right ventricular compliance, or both) predicted the presence of pulmonary arterial hypertension with a sensitivity of 87% and a specificity of 80%. These results suggest that pulsed Doppler echocardiography of the inferior vena cava may be a useful though imperfect method of detecting pulmonary arterial hypertension in patients with chronic obstructive lung disease.

The purpose of this study was to evaluate prospectively the occurrence of cardiac arrhythmias during the combined therapy with intravenous aminophylline and terbutaline in 29 consecutive patients with status asthmaticus. The 24-hour Holter recordings were performed during continuous intravenous infusions of aminophylline (0.56 +/- 0.20 mg/kg/h) and terbutaline (0.034 +/- 0.014 microgram/kg/min). Serum theophylline concentration was 12.1 +/- 3.8 micrograms/ml and never reached the toxic level (greater than 20 micrograms/ml). Premature ventricular contractions (PVCs) were absent in 35 percent of patients and 48 percent had rare unifocal PVCs (less than 10/h). Only 17 percent of patients (five of 29) exhibited severe ventricular arrhythmias: PVCs greater than 10/h (n = 3), multifocal PVCs (n = 1); and a short run of ventricular tachycardia (n = 1). Serious supraventricular arrhythmias occurred in only 7 percent of patients (two of 29) who developed sustained runs of atrial tachycardia. These arrhythmias were always clinically well tolerated and spontaneously resolved without any antiarrhythmic treatment. We conclude that severe arrhythmias are rarely observed during combined therapy with aminophylline and terbutaline in status asthmaticus.