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Introduccion La prevalencia de la enfermedad pulmonar obstructiva cronica (EPOC) varia considerablemente entre las diferentes areas geograficas estudiadas. En Espana hay 2 estudios epidemiologicos que muestran una prevalencia entre el 9 y el 10% en poblacion mayor de 40 anos. No obstante, ninguno de ellos ha incluido a las Islas Canarias, region de interes por sus caracteristicas climaticas y su alta prevalencia de tabaquismo. Material y metodos A partir de una muestra poblacional de 596.478 personas se selecciono una muestra aleatorizada de 1.353 individuos entre 40 y 70 anos. Los participantes rellenaron un cuestionario y posteriormente realizaron una espirometria con test de broncodilatacion si existia obstruccion. Se diagnostico EPOC cuando el cociente FEV1/FVC despues de la broncodilatacion era menor de 0,70. Resultados La prevalencia de EPOC fue del 7,3% (IC 95%: 5,5-9,5), siendo mayor en varones que en mujeres (8,7% vs. 6,3%, p = 0,134). La tasa de tabaquismo fue del 29,4% (IC 95%: 25,4-33,1), tambien mayor en los varones que en las mujeres (35,1% vs 25,4%, p < 0,001). La prevalencia de EPOC estratificada segun la gravedad de la obstruccion, en base a los criterios GOLD, fue del 16% en el grupo i, del 69,9% en el ii, del 10,4% en el iii y del 3,3% en el iv. El infradiagnostico fue del 71,6% y el infratratamiento, del 63,5%. Conclusiones A pesar de tener una de las tasas de tabaquismo mas altas de Espana, la prevalencia de EPOC en las Islas Canarias es menor que en la mayoria de las zonas espanolas estudiadas.

Introduction The prevalence of chronic obstructive pulmonary disease (COPD) varies significantly among the different geographical areas reported. In Spain, two epidemiological studies have shown a prevalence of 9–10% in the population aged over 40. However, neither of these studies included the Canary Islands, which are of interest due to their climatic conditions and high incidence of smoking. Materials and methods A random group of 1353 subjects aged between 40 and 70 years was selected from a sample population of 596 478 individuals. Participants completed a questionnaire and then performed spirometry with bronchodilator testing if obstruction was observed. COPD was diagnosed when the post-bronchodilator FEV1/FVC ratio was less than 0.70. Results The prevalence of COPD was 7.3% (95%CI: 5.5–9.5) and was higher in males than in females (8.7% vs 6.3%, P=.134). The incidence of smoking was 29.4% (95%CI: 25.4–33.1) and was also higher in males than in females (35.1% vs 25.4%, P

Carlos Cabrera,1 Ciro Casanova,2 Yolanda Martín,3 Virginia Mirabal,3 María del Carmen Sánchez,4 Felisa Álvarez,5 Gabriel Juliá,1 Pedro Cabrera-Navarro,1 Miguel Ángel García-Bello,6 José María Marín,7 Juan Pablo de-Torres,8 Miguel Divo,9 Bartolomé Celli9 1University Hospital of Gran Canaria Dr Negrín, Respiratory Service, Las Palmas de Gran Canaria, Spain; 2University Hospital Nuestra Señora de la Candelaria, Respiratory Service, Santa Cruz de Tenerife, Spain; 3Arucas Health Center, Primary Care Las Palmas de Gran Canaria, Spain; 4Cueva Torres Health Center, Primary Care Las Palmas de Gran Canaria, Spain; 5La Feria Health Center, Primary Care Las Palmas de Gran Canaria, Spain; 6University Hospital of Gran Canaria Dr Negrín, Investigation Unit, Las Palmas de Gran Canaria, Spain; 7University Hospital Miguel Servet, Respiratory Service, Zaragoza, Spain; 8Navarra University Clinic, Respiratory Service, Pamplona, Spain; 9Brigham and Women’s Hospital, Pulmonary and Critical Care Service, Boston, MA, USA Introduction: Guidelines recommendations for the treatment of COPD are poorly followed. This could be related to the complexity of classification and treatment algorithms. The purpose of this study was to validate a simpler dyspnea-based treatment algorithm for inhaled pharmacotherapy in stable COPD, comparing its concordance with the current Global Initiative for Obstructive Lung Disease (GOLD) guideline.Methods: We enrolled patients who had been diagnosed with COPD in three primary care facilities and two tertiary hospitals in Spain. We determined anthropometric data, forced expiratory volume in the 1st second (percent), exacerbations, and dyspnea based on the modified Medical Research Council scale. We evaluated the new algorithm based on dyspnea and exacerbations and calculated the concordance with the current GOLD recommendations.Results: We enrolled 100 patients in primary care and 150 attending specialized care in a respiratory clinic. There were differences in the sample distribution between cohorts with 41% vs 26% in grade A, 16% vs 12% in grade B, 16% vs 22% in grade C, and 27% vs 40% in grade D for primary and respiratory care, respectively (P=0.005). The coincidence of the algorithm with the GOLD recommendations in primary care was 93% and 91.8% in the respiratory care cohort.Conclusion: A simple dyspnea-based treatment algorithm for inhaled pharmacotherapy of COPD could be useful in the management of COPD patients and concurs very well with the recommended schema suggested by the GOLD initiative. Keywords: COPD, treatment, algorithm, primary care

There are no previous population-based studies assessing the prevalence of Blomia tropicalis (BT). This investigation analyzes the prevalence of sensitization to BT and its contribution to asthma and related diseases among young adults in the Canary Islands.From a random sample of 9506 adults, aged between 20 and 44, who had previously answered a short respiratory questionnaire, a further 20% random sample was drawn. All participants filled in an extensive questionnaire, and they underwent spirometry and bronchial hyperresponsiveness (BHR) test and skin testing to several allergens as well as the determination of total IgE and specific IgE.The prevalence of positive skin tests to BT was 13.8% (95% confidence interval [CI] 10.6-17.9%) and that of BT-specific IgE 17.9% (95% CI 14.2-24.5%). Sensitization to BT (positive skin tests or positive specific IgE) was 20.9% (95% CI 16.9-25.5%). Most of the subjects sensitized to BT were also sensitized to Dermatophagoides pteronissimus; however, only 7% displayed monosensitization to BT. Among subjects who exhibited BHR, sensitization to BT reached 46.7% (95% CI 32.7-60.9%), among those with asthma 50% (95% CI 26.8-73.2%), in subjects with rhinitis 37.2% (95% CI 28.1-47.6%), and in those suffering from dermatitis 25.9% (95% CI 18.7-34.5%). A strong association of BT sensitization with BHR and asthma before and after 15 years was found.The prevalence of sensitization to BT among young adults in the Canary Islands is high, and it displays a close relationship with allergic respiratory diseases and dermatitis.

Objective To evaluate the prevalence of and risk factors for asthma and related conditions in the Canaries, Spain. Methods From a randomised sample of 9506 adults aged 20-44 years who answered a short questionnaire, a random sample corresponding to 20% of the original was taken. Subjects classified as symptomatic in the previous survey and who were not included in the random sample were also invited to participate. The subjects completed a respiratory questionnaire, and underwent spirometry, bronchial hyperresponsiveness (BHR) test, skin tests and immunoglobulin E (IgE) measurements. Results The random sample included 593 subjects. The prevalence of skin sensitisation to mites was 30.3% (95%CI 26.7-34.2) and the prevalence of IgE to mites 30.5% (95%CI 26.2-35.2). A prevalence of 40.6% (95%CI 35.9-45.5) was found for atopy, 14.1% (95%CI 11.1-17.1) for BHR and 4.2% (95%CI, 2.5-5.9) for asthma. The risk factors most strongly associated with asthma were atopy (OR 4.89, 95%CI 3.07-7.78) and respiratory infection before the age of 5 years (OR 2.78, 95%CI 1.66-4.67). Conclusion This study shows a high prevalence of sensitisation to mites, atopy, BHR and asthma in the Canaries, similar to that observed in English-speaking countries. We suggest that these findings could partially result from climatic conditions.

Objective We sought to compare the long-term effects of conventional and simplified thoracic sympathectomy on cardiopulmonary function. Methods We performed a prospective and randomized study of 32 patients with diagnoses of primary hyperhidrosis who were candidates for either conventional or simplified thoracic sympathectomy. Patients were randomized according to the type of procedure: conventional thoracic sympathectomy (18 patients) and simplified thoracic sympathectomy (14 patients). Before surgical intervention, forced spirometry, body plethysmography, measurement of the diffusing capacity of the lung for carbon monoxide (Dlco), and exercise tests were carried out in all patients. These evaluations were performed again 1 year after the procedure to assess the long-term effects of sympathectomy. Results Lung function tests revealed a significant decrease in forced expiratory volume in 1 second (FEV 1 ) and forced expiratory flow between 25% and 75% of vital capacity (FEF 25%–75% ) in both groups (FEV 1 of −6.3% and FEF 25%–75% of −9.1% in the conventional thoracic sympathectomy group and FEV 1 of −3.5% and FEF 25%–75% of −12.3% in the simplified thoracic sympathectomy group). Dlco and heart rate at rest and maximal values after exercise were also significantly reduced in both groups (Dlco of −4.2%, Dlco corrected by alveolar volume of −6.1%, resting heart rate of −11.8 beats/min, and maximal heart rate of −9.5 beats/min in the conventional thoracic sympathectomy group and Dlco of −3.9%, Dlco corrected by alveolar volume of −5.2%, resting heart rate of −10.7 beats/min, and maximal heart rate of −17.6 beats/min in the simplified thoracic sympathectomy group). Airway resistance increased significantly in the group of patients undergoing conventional thoracic sympathectomy (+13%). Despite all these changes, the patients remained asymptomatic. No significant differences were found between the conventional and simplified thoracic sympathectomy groups. Conclusions Simplified and conventional thoracic sympathectomy resulted in a long-term reduction in FEV 1 , FEF 25%–75% , Dlco, and resting and maximal heart rate, as well as a mild but significant increase in airway resistance in the conventional thoracic sympathectomy group, without any clinical consequence to the patient. These changes were unrelated to the level of transection of the thoracic sympathetic chain.

Objective.Pulmonary arterial hypertension (PAH) prevalence has been reported to be between 0.5% and 17% in systemic lupus erythematosus (SLE). This study assessed PAH prevalence and predictors in an SLE cohort.Methods.The Borg dyspnea scale, DLCO, N-terminal pro–brain natriuretic peptide (NT-proBNP), and Doppler echocardiographic (DE) were performed. An echocardiographic Doppler exercise test was conducted in selected patients. When DE systolic pulmonary arterial pressure was ≥ 45 mmHg or increased during exercise > 20 mmHg, a right heart catheterization was performed. Hemodynamic during exercise was measured if rest mean pulmonary arterial pressure was < 25 mmHg.Results.Of the 203 patients with SLE, 152 were included. The mean age was 44.9 ± 12.3 years, and 94% were women. Three patients had known PAH. The algorithm diagnosed 1 patient with chronic thromboembolic pulmonary hypertension and 5 with exercise-induced pulmonary artery pressure increase (4 with occult left diastolic dysfunction). These patients had significantly more dyspnea, higher NT-proBNP, and lower DLCO.Conclusion.These data confirm the low prevalence of PAH in SLE. In our cohort, occult left ventricular diastolic dysfunction was a frequent diagnosis of unexplained dyspnea. Dyspnea, DLCO, and NT-proBNP could be predictors of pulmonary hypertension in patients with SLE.

Introduction: in all epidemiological studies there are always a proportion of never smoking COPD patients. This study aims to characterize the difference between smokers and never smokers in COPD. Methods: we enrolled COPD patients attending pulmonary care in a tertiary hospital. Never smokers had a history of less than 0.1 pack years. Anthropometric measures, spirometry, plethysmography, 6MWT and blood tests were performed. Results: we enrolled 51 non smokers and 165 smokers with COPD. There was no difference in age or FEV1% between both groups. BMI and fat free mass were statistically higher in the non smoker COPD group. The IC/TLC, DLCO, walked distance in the 6MWT and the BODE index were also significantly higher in this group. However, comorbidities, measured by both the Charlson and the COTE index, were significantly lower in the non smoking COPD group. Conclusion: in spite of having the same diagnosis, the non smoker group has a milder disease than the smoker group. This fact hints the possibility of two different clinical entities.

Despues de varias decadas de investigacion en biologia celular y molecular, se ha logrado un gran avance en el conocimiento de la patogenia del asma. Hoy se conoce, en gran parte, la secuencia de las reacciones biologicas que ponen en marcha los rasgos fenotipicos del asma: la obstruccion al flujo aereo, la inflamacion y la hiperrespuesta bronquial. Este conocimiento ha permitido senalar a la inmunoglobulina (Ig) E como una de las dianas a neutralizar, ya que es un componente inicial en los complejos procesos inflamatorios del asma. El omalizumab, un anticuerpo monoclonal humanizado, consigue bloquear la IgE libre y mejorar enfermedades alergicas como la rinitis y el asma. En esta revision, se analizan los fundamentos del tratamiento con anticuerpos monoclonales y se actualiza la accion del omalizumab desde el punto de vista farmacologico y clinico.

Inhaled nitric oxide (iNO) has been shown to be a potent and selective vasodilator in pulmonary arterial hypertension (PAH). However, the clinical experience in prolonged treatment is limited. We assess the safety and effectiveness of long-term administration of iNO in severe PAH. Two female patients were admitted to our hospital because of severe dyspnea (World Health Organization functional class IV) and hypoxemia. They were diagnosed with PAH (primary and secondary to congenital heart disease) and treated with iNO for 2 years. The delivery system consisted of an NO tank of 800 ppm, a modified gas-pulsing device, and nasal cannulas. On iNO treatment the patients showed remarkable improvement of symptoms, oxygenation and 6-min walk distance. After 16 months the patients began to experience a progressive rebound of symptoms. A phosphodiesterase type 5 inhibitor (dipyridamole) was added to iNO. This intervention proved useful in improving clinical deterioration and hemodynamics. This is the first study reporting 2-year iNO therapy in 2 patients with primary and secondary pulmonary hypertension. The combination of dipyridamole with iNO augments the pulmonary vasodilatation and may be useful in managing PAH.

La fibrosis quistica ha dejado de ser una enfermedad exclusivamente pediatrica y, cada vez con mayor frecuencia, los medicos de adultos tienen que atender a este tipo de enfermos. Esta situacion deriva de dos condicionantes: mayor supervivencia de los enfermos con fibrosis quistica clasica y aparicion de nuevas formas clinicas. En la poblacion caucasiana, la fibrosis quistica es la enfermedad hereditaria mas frecuente entre las potencialmente mortales. En Espana tiene una frecuencia de uno entre 2.810 recien nacidos

We studied the cases of three siblings with a history of chronic bronchitis and infertility. The electron-microscopic investigation of the tracheal and bronchial biopsies showed a ciliary defect consisting in the absence of the central microtubules and the transposition of a peripheral doublet. This is a rare and infrequently reported abnormality included in the primary ciliary diskinesia syndrome.

Los textilomas, reacciones inflamatorias contra cuerpos extranos de tipo textil, representan una complicacion posquirurgica poco frecuente. La diversidad de sintomas y signos radiologicos con que se manifiestan contribuye a que su diagnostico se confunda con un proceso de tipo neoplasico. Los hallazgos descritos con la tomografia por emision de positrones (PET), tecnica poco habitual en el manejo diagnostico de esta entidad, pueden condicionar falsos positivos neoplasicos. Describimos el caso de un varon de 56 anos, que 23 anos despues de una cirugia de neumotorax presento una masa intratoracica indicativa de neoplasia en la PET, cuyo diagnostico final fue de textiloma.

Patients with acute asthma exacerbation (AAE) represent agrowing health problem in the Emergency Departments (ED)[1–5]. The assessment of AAE severity is of great importancebecause it will determine the level and place of care [6].In this sense, tools to assess acute asthma severity are helpful[9]. Dankner et al. [7] retrospectively tested a simplifiedseverity score (SSS) on more than 500 adult patients thatvisited an ED for AAE. The following variables wereincluded in the SSS upon arrival: pulse rate, respiratorywheezes, rales, prolonged expiration, oxygen saturation andthe use of accessory muscles. The severity of the AAE wasgraded as mild, moderate or severe.We have read with interest this interesting originalcontribution. There are, however, a few issues we think arenoteworthy to review. In regard to patient selection anddiagnosis, the authors recruited adult patients younger than35 years so the results may not be applicable to other agegroups. It is also unknown if the diagnosis of asthma wasmade prior to the ED visit [8].The measurement of bedside clinical signs is limited fordifferent reasons: (A) interpretation of clinical signs dependon the subjectivity and experience of the treating physician.Obviously, patients with most severe AAE will present theworst physical findings. (B) Although PF is the gold standard,most EDs do not have the capacity or expertise to obtain thismeasurement in a meaningful way. The authors stated thatbaseline PF values were available in close to 50% of patients.In this case, they should analyze their data and compare it tothe SSS, since this is a good way to suggest validity. (C) Anadditional patient’s factor not included in the score isalertness [9]. Even though somehow subjective, it may helpthe clinician in the patient’s assessment.There are also aspects relevant to effectiveness of therapythat, although not practical for a simplified score, ought to betaken into account in everyday practice: poor asthma control,noncompliance with medications, intake of high dosemedication, psychiatric issues, socioeconomic status, accessto heath care and exposure to cigarette smoke. Some of thesemight be determinant in deciding to hospitalise someone witha ‘‘mild’’ AAE.Regarding the treatment used, it is surprising that fewerthan 60% of patients with moderate AAE and fewer than 80%of patients with severe AAE received systemic steroids.In regard to the use of ipratropium, fewer than 40% of patientsreceived this drug because of unavailability. Nowadays, manypatients with AAE may receive ipratropium together withalbuterol, specially, if symptoms persist. If ipratropium isadministered, it might lead to fewer hospitalisations across thewhole group of patients. Finally, the use of xanthines acrossthe severity range of AAE was quite high. The availablecurrent evidence suggests that they should only be consideredfor those with AAE severe enough to not respond to first linetherapy [8]. Therefore, we can say that treatment of patients inthe original study did not follow standard of care. If thepatients were under-treated or inappropriately treated, theresults can hardly be deemed valid.The authors conclude that the SSS has a good potentialdiscriminatory capacity to help select patients for discharge oradmission. However, they ignore that a dynamic evaluation inthe ED of AAE patients is preferred. We know that the timingof response to treatment varies among patients with AAE andalso depends on the type – type 1 or type 2 – of exacerbation.In this sense, we think that a repeated SSS value just beforeclinical decision takes place – e.g. 2–3h after the firstassessment – would test the score’s performance in a morereliable manner. So, the lack of a follow-up score limits thevalidity of results [10].Workloads and cost implications: the authors argue thatuse of SSS does not require additional costs in the ED [11].However, it would be interesting to know about thephysician’s and nurse’s workload, since it could affectadherence with filling up the score. Educational actions toimprove compliance with the test may be helpful.In summary, we agree that a score could help in thedecision-making process in the ED, and it should serve as aguide. Given the retrospective nature of the study and the

Study objective To assess the usefulness of quantification of bronchoalveolar lavage (BAL) cells containing intracellular organisms (ICO) in the diagnosis of ventilator-associated pneumonia. Design The reliability of cytologic analysis in comparison with the protected specimen brush (PSB) and BAL quantitative cultures has been assessed in a prospective study. Setting An intensive care unit of a tertiary-referral teaching hospital. Patients A total of 33 ventilated patients with suspected pneumonia based on clinical grounds and radiographic findings. Interventions All patients underwent fiberoptic bronchoscopy within the first 24 h after clinical suspicion of pneumonia. Specimens were obtained by PSB and BAL and were processed for quantitative cultures using standard methods. Two 0.5-ml samples of resuspended original BAL fluid were centrifuged and stained with Gram and modified May-Grunwald-Giemsa for differential cell counts and percentage of cells with ICO. Results Pneumonia was the final diagnosis in 16 (49 percent) of the 33 patients. In 14 (42 percent) patients, pneumonia was excluded and in the remaining 3 the diagnosis was uncertain. Twelve of the 16 patients with pneumonia had their conditions diagnosed by PSB, 14 by BAL, and 10 by quantification of ICO. Only one patient's condition was diagnosed exclusively by cytologic examination. There were no false-positive results with any of the diagnostic techniques. Conclusions Microscopic identification of ICO in cells recovered by BAL allows early and accurate diagnosis of pneumonia in mechanically ventilated patients. However, the sensitivity of this technique is lower than with either PSB or BAL.

Background Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator, but therapeutic experience in patients with severe pulmonary hypertension is scarce. Methods Eleven patients with severe pulmonary hypertension, 6 due to pulmonary arterial hypertension and 4 due to chronic thromboembolic disease, were selected for iNO therapy. A phosphodiesterase type 5 inhibitor (PDE5i) was added in cases of clinical worsening. In this study we evaluate the clinical effectiveness and safety of long-term treatment with iNO either alone or combined with a PDE5i. Results After 1 month of iNO administration, improvements were observed in World Health Organization functional class, Borg scale ( p = 0.003), brain natriuretic peptide levels ( p = 0.002) and 6-minute walk test ( p = 0.003). After 6 months of treatment, 7 patients had clinical deterioration that was reversed upon adding a PDE5i. One of these patients died in Month 8 and another underwent pulmonary transplantation in Month 9. The clinical condition of the remaining 9 patients was unchanged after 1 year. A second right catheterization showed improvement in mean pulmonary arterial pressure (66 ± 15 mm Hg to 56 ± 18 mm Hg; p = 0.01), pulmonary vascular resistance (1,234 ± 380 dyn/s/cm 5 to 911 ± 410 dyn/s/cm 5 ; p = 0.008) and cardiac index (2.0 ± 0.4 liters/min/m 2 to 2.5 ± 0.4 liters/min/m 2 ; p = 0.04). There was no significant increase in methemoglobin, no worsening of pulmonary function and no sudden withdrawal syndrome. Conclusions We suggest that iNO therapy alone or in combination with a PDE5i could be a therapeutic alternative for severe pulmonary hypertension.

Gossypibomas from inflammatory reactions to textile foreign bodies are a rare postoperative complication and are easily confused with neoplastic processes because of their diversity of symptoms and radiographic signs. Positron emission tomography (PET) is seldom used to diagnose gossypibomas and PET findings can result in false positives for a diagnosis of neoplastic disease. We describe the case of a 56-year-old man in whom PET findings showed an intrathoracic mass suggesting a tumor. The final diagnosis was gossypiboma, identified 23 years after pneumothorax surgery.

The aim of this investigation was to evaluate the contribution of cephalometry to a statistical model integrating clinical, physical, and oximetric variables, to reduce demands for polysomnographies. Two hundred and twenty-five consecutive patients that had been referred to the sleep clinic for suspected obstructive sleep apnea (OSA) were studied. The clinical assessment of all patients consisted of a sleep related questionnaire, the Epworth sleepiness scale, and a physical examination. In addition, they all underwent spirometry, cephalometry, and a full polysomnography. The clinical variables related with OSA were questions concerning witnessing of apneas by bed partners, intensity of snoring, a history of hypertension, and nocturia. A significant relation was also found with score on the Epworth scale, sex, age, body mass index, neck and waist circumferences, total number and frequency of oxygen desaturations, and the lowest oxygen saturation value. Significant cephalometric measurements were: the linear distance from gonion to gnathion, from the hyoid bone to the mandibular plane, and from the posterior nasal spine to the tip of the soft palate, and the thickness of the uvula as well. A statistical model was built to estimate a patient's probability of having OSA based on clinical variables, physical examination, pulse oximetry, and cephalometry. The validation of this model demonstrated a remarkable ability in reducing the number of polysomnographic studies. We conclude that cephalometry combined with clinical variables, physical examination, and nocturnal oximetry is useful in the diagnosis of OSA and enables the sparing of a considerable number of polysomnographies.

Transbronchial fine-needle aspiration (TBFNA) is a valuable and low-risk procedure that provides access to mediastinal nodes. To learn if increased experience improved TBFNA performance, we compared overtime TBFNA diagnostic yields between a skilled bronchoscopist and another without experience on TBFNA technique. We found higher TBFNA yields in the experienced bronchoscopist (p0.001); however, after some experience, the TBFNA reliability improved (p0.02) and the use of the procedure increased (p0.0001). Thus, to achieve acceptable TBFNA results, a training period is required that we estimate in about 50 procedures.

Background The purpose of this study was to evaluate the long-term and midterm effects of thoracic sympathectomy on pulmonary function and to assess the influence of the sympathetic nervous system on bronchomotor tone. Methods Thirty-seven consecutive patients were diagnosed with primary hyperhidrosis requiring thoracic sympathectomy and were included in this study. Spirometry and methacholine challenge testing were performed before and 3 months after surgery. To assess the long-term effects of the intervention, another spirometric study was performed 1 year later. Results Spirometry 3 months after surgery showed a significant decrease in the forced vital capacity (−5.2%), the forced expiratory volume in the first second (−6.1%), and the forced expiratory flow between 25% and 75% of vital capacity (−5.1%). Whereas methacholine challenge testing before surgery was positive in 3 subjects (2 of whom were asthmatic), it was positive in 6 patients after the procedure; differences were not statistically significant. After 12 months, forced vital capacity started recovering, and forced expiratory volume in the first second and forced expiratory flow rate 25% to 75% showed a sustained and significant reduction (−2.8% and −11.2%, respectively); however, patients remained asymptomatic. Conclusions We conclude that thoracic sympathectomy generates a mild, although significant, impairment of the bronchomotor tone, with no clinical consequences. These results suggest that the sympathetic nervous system is involved in pulmonary bronchomotor tone.

We describe a case of long-term administration of nitric oxide (NO) in a 32-year-old man who was admitted with exertional dyspnea and anasarca. A diagnosis of primary pulmonary hypertension was made. An acute vasodilator trial with inhaled NO showed a 5% reduction of the mean pulmonary artery pressure. Long-term NO inhalation therapy was initiated. Twenty days later, the dyspnea improved, the anasarca resolved, and the PaO(2) level increased. After 12 months of NO therapy, the patient remained stable and no signs of toxicity or tachyphylaxis were observed. To our knowledge, this is the first report of 1 year of continuously inhaled NO in an adult patient with primary pulmonary hypertension. These findings suggest that prolonged NO therapy might be an effective alternative, at a lower cost, to the continuous IV infusion of epoprostenol.