Search

Allergic rhinoconjunctivits and asthma are frequent diseases. About one in ten asthma cases is caused by an occupational hazard, either by an allergic or a non-immunologic mechanism. Primary or secondary preventive measures should be able to prevent these cases. Often, occupational rhinitis precedes the development of occupational asthma. Important causative agents are flours, plant and enzyme powders, laboratory animals, latex, isocyanates and hardeners, epoxy resins, acrylates, formaldehyde and welding fumes. Early diagnosis and the installation of protective measures are decisive for the prognosis of occupational respiratory disease.

Chronic bronchitis (CB) shows an increasing global morbidity and mortality with major impact on socioeconomics. N-Acetylcysteine (NAC), previously used as a mucolytic compound in CB, has also antioxidative effects. Furthermore it influences intrabronchial bacterial colonisation. In a randomised pilot study of 24 patients (16-male, 8 female, mean age 66 +/- 10 years) with acute exacerbation of CB and positive bacterial culture in the sputum, the addition of twice daily 600 mg NAC to standard antibiotic therapy lead to a significantly higher bacterial eradication rate (70 % versus 36 %, p < 0.03). Clinical studies suggest that treatment with NAC has different effects in CB including a reduction of the number and duration of acute exacerbation episodes and possibly influences lung function. The improvement of symptoms and quality of life also has an impact on socio-economic costs. The use of NAC in CB as an antioxidative rather than a mucolytic compound should be considered. However, further placebo controlled studies are undergoing to definitively establish the role of NAC for the treatment of CB and COPD.

Unlabelled: The clinical course of cystic fibrosis (CF) is characterised by chronic bronchial infection with Pseudomonas aeruginosa. Therapy with inhaled aminoglycosides was introduced to decrease the rate of infectious exacerbations and to delay pulmonary progression. However, development of resistance to aminoglycosides is frequent. Few investigations are available into the resistance profile under treatment with colistin. Antibiotic resistance to colistin was analysed in 44 adult CF patients treated with inhaled colistin. Resistance to aminoglycosides was observed in 86% of cases (38/44) before therapy and decreased to 43% (19/44) under treatment with colistin. Five patients (11%) developed polymyxin resistance. After cessation of therapy pseudomonas became sensitive to polymyxin within a few months and enabled colistin to be reintroduced. In addition, we performed a pilot study analysing the effect of inhaled colistin on the growth of pseudomonas. The number of Pseudomonas aeruginosa decreased from 16.7 million (CFU) bacteria per ml sputum to 2.9 million under therapy with colistin. There was a more than tenfold increase in bacterial counts after inhaled colistin was stopped. Genotyping revealed no change in the type of pseudomonas strains., Conclusion: Development of resistance to polymyxin is not rare under long-term treatment with inhaled colistin and requires temporary interruption of therapy. Sputum cultures should therefore be tested regularly for polymyxin resistance in patients treated with inhaled colistin.

Unlabelled: The clinical course of cystic fibrosis is characterised by pulmonary involvement with mucus retention, chronic pulmonary infection and parenchymal inflammation. Recurrent infectious exacerbations are usually accompanied by a fall in lung volumes. This pilot study investigated whether exacerbations can be detected early by daily spirometry. Ten patients with cystic fibrosis (5 female; 5 male; mean age 24.9 years) performed daily spirometry using a portable transtelephonic spirometer (Spirophone). Infectious exacerbations were diagnosed on clinical grounds and treated without knowledge of the spirometry results. Data of 9 patients recorded over a period of 5-11 months were analysed. One patient was excluded due to non-compliance. A total of 20 infectious exacerbations occurred during the observation period. A fall of at least 20% in one or more of the following parameters was observed in 90% (18/20) of exacerbations: FVC, FEV1, PEF, and FEF25/75. A daily drop in lung volumes of 0.7% to 1.2% was recorded beginning at a median of 33 (20 to 120) days before infectious exacerbations were diagnosed. There was a 2-3% daily improvement in spirometric data under treatment with antibiotics., Conclusion: Daily spirometry allows early recognition of pulmonary infectious exacerbations in patients with cystic fibrosis. Daily spirometry may be used as an indicator for early antibiotic treatment.

Human lung transplantation was successfully performed in the early eighties and is now an option for patients with endstage lung disease, which is associated with poor survival. Most frequent indications for lung transplantation are emphysema, cystic fibrosis, fibrosing alveolitis, primary pulmonary hypertension and Eisenmenger's syndrome. Single lung transplantation (SLT) is most often performed in emphysema, fibrosing alveolitis and other diseases which are not associated with chronic infection of the lung. Double lung transplantation was recently replaced by the technique of sequential single lung or bilateral lung transplantation (BLT). Cardiopulmonary bypass can often be avoided and problems of the airway anastomosis are less frequent using BLT. Main indications for this procedure are cystic fibrosis, bronchiectasis and primary pulmonary hypertension (PPH). In PPH often only SLT is performed. Cor pulmonale is reversible following SLT or BLT even if the heart is not replaced. Combined heart-lung transplantation (HLT) is reserved for some cases of Eisenmenger's syndrome and few centers still prefer HLT in patients with cystic fibrosis. Patients are usually accepted for transplantation when they are considered to have life expectancy of 12 to 24 months. Quality of life and physical working capacity are severely decreased and patients suffer dyspnea NYHA grade III or IV. Most of the patients are hypoxic and need continuous oxygen therapy. Hypercapnia is also a negative predictive factor for survival without transplantation. In PPH cardiac index of less than 2 litres/m2 is associated with poor outcome. Not only absolute values for FEV1 and pO2 have to be considered in finding the best moment for assessment for transplantation but the clinical course of the disease during previous months and years also has to be taken into account. Contraindications to transplantation include acute infection, concomitant diseases of other organs, bronchial carcinoma and psychiatric disorders if noncompliance is likely. To achieve good results after lung transplantation, proper donor and recipient selection, experienced surgery and careful postoperative management are essential. Complications must be diagnosed early to provide effective treatment. Most complications occur within the first months after surgery. Early complications include primary organ failure, pleural bleeding, problems at the site of the airway anastomosis, infection and acute rejection. Acute rejection is common but can be treated successfully if diagnosed early.(ABSTRACT TRUNCATED AT 400 WORDS)

Up to 85% of patients with bronchogenic carcinoma are inoperable at the time of diagnosis and treatment remains largely palliative. Prognosis depends on the clinical tumor stage. In non-small cell carcinoma the clinical stages (I-IV) are defined according to the TNM classification, whereas in small cell carcinoma limited disease is distinguished from extensive disease. Neither classification accurately takes endobronchial tumor spread into account. At the time of diagnosis up to 30% of all lung cancer patients present with central airway obstruction and clinical signs of dyspnea, atelectasis and pneumonia. Most patients with central airway stenosis have inoperable tumors (stage IIIb and IV) and have until recently undergone conventional treatment consisting exclusively of chemo- and radiotherapy. Currently the best results are obtained with combined chemoradiotherapy. The rapid developments in the area of endobronchial treatment modalities enable us to relieve bronchial obstructions fast and safely. This achieves immediate symptomatic relief which in many cases is a precondition for starting chemo- or radiotherapy. Successful reopening of a major airway helps to prolong local tumor control and thus survival. Patients with inoperable lung cancer and obstruction of central airways should undergo initial endobronchial therapy followed by conventional chemo-radiotherapy.

This is an overview for the non-specialist of the pathophysiology, workup and treatment of the obstructive sleep apnea syndrome. The mechanisms leading to upper airway closure during sleep are discussed, as well as the current theoretical and experimental concepts for the apnea-induced arousal response and the consequent changes in sleep architecture and quality. Epidemiological data are summarized, with special reference to the problems of non-uniform definition criteria and examination techniques applied. In conclusion, a practical workup strategy and the current treatment options are summarized.

4 of the 198 patients treated by bone marrow transplantation in Basel, Switzerland, with a follow-up of more than one year after therapy, developed a severe restrictive pneumopathy. In none of the 4 patients could an infectious pathogen be isolated, but all of them had signs of a chronic graft-versus-host disease. The 4 cases are described in detail.

For early diagnosis of cytomegalovirus (CMV) infection after renal transplantation, 18 patients were monitored within the first 3 months. Blood leukocytes were assayed weekly for the presence of the CMV matrix protein p65 (antigenemia assay) and CMV DNA by the polymerase chain reaction (PCR). In 12 out of 18 patients, 70 (37.8%) of 185 blood samples were positive by antigenemia assay or by PCR. 49 and 115 samples concurrently were positive and negative by both tests. 8 blood samples were positive only by the antigenemia assay and 13 only by PCR. Therefore, the relative sensitivity of PCR and of antigenemia assay was 88.6% and 81.4% respectively. In 9 of 10 patients who were pre-transplant CMV seropositive and in 4 of 7 patients who were pre-transplant CMV seronegative and received a graft from a seropositive donor, CMV infection was detected by positive antigenemia and/or PCR. Four of these patients developed CMV disease. In all these patients, antigenemia assay and PCR were positive 7 to 16 days prior to onset of clinical symptoms. Antigenemia and PCR are rapid and sensitive methods for the detection of CMV infection 1 to 2 weeks prior to disease. In addition, the semi-quantitative assay of antigenemia enables monitoring of the efficacy of antiviral therapy.

Mycoplasma hominis (M. hominis) frequently colonizes the genital tract, but is rarely isolated from the respiratory tract. Dissemination of M. hominis has been documented in women with a febrile illness after delivery. Spontaneous recovery is the rule. A 32-year-old woman in the 29th week of pregnancy was hospitalized for pneumonia. She had to be ventilated for respiratory insufficiency and thoracic empyema. The child was delivered by section due to signs of stress in cardiotocography. In the ensuing days the mother's condition worsened, with fever, weight loss and persistent pleural effusion. Even after decortication and treatment with ceftriaxone fever and pleural effusion persisted. M. hominis was found in pleural fluid cultures. Treatment with doxycycline led to rapid defervescence and an improvement of the patient's condition.

Eight patients with life threatening hyperkalemia were treated in the intensive care unit over a period of 2 years. Serum potassium at admission was 7.1-11.2. Two patients had to be resuscitated and 3 exhibited quadriplegia or paralyses but were alert. Seven showed marked ECG change: in 5 the QRS-complexes were extremely broadened and in one case an AV-rhythm was observed; the atrial wave was absent in all 7 patients. Renal failure was present in 7 of 8 patients. In 6 of these 8 cases drugs were also involved in the development of hyperkalemia. The following therapeutic procedure is recommended for hyperkalemia: (1) injection of calcium, (2) inhalation or injection of beta 2-mimetics (well documented in the literature; clinical experience limited), (3) insulin and glucose i.v., (4) sodium bicarbonate, but only in case of metabolic acidosis, (5) hemodialysis, (6) cation exchange resins or furosemide in non-acute situations.