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Between January 1985 and December 1991, six patients underwent arterial and bronchial sleeve resections of the left upper lobe. Preoperative and postoperative spirometry, preoperative split pulmonary radionuclide ventilation/perfusion (V/Q) scans and postoperative bronchoscopy were obtained in four patients. Postoperative serial digital vascular images (DVI) of the pulmonary artery were obtained in three patients and one patient had a post-operativ V/Q scan. For each patient the preoperative and postoperative forced expiratory volume in 1s (FEV 1 ) were determined to assess the postoperative ventilatory recovery. At bronchoscopy all patients had a patent bronchial anastomosis. At postoperative DVI, in three patients. vascularization of the residual left lung was delayed and less intense compared with the non-operated right lung. Postoperative V/Q scan, in one patient, showed reduced ventilation and perfusion of the residual lung. Preoperative and postoperative FFV 1 of the four patients were 2688/1998 ml, 2154/1752 ml, 2618/2100 ml and 2277/2015 ml. Operative mortality was zero. One patient had a postoperative atelectasis of the left lower lobe. In our series, ventilation and vascularization of the reimplanted and revascularized left lower lobe were reduced. But, in our opinion, the preserved residual lung parenchyma was still a relevant advantage.

Although home recording of peak expiratory flow (PEF) is considered useful in managing asthma, little is known about the relationship of PEF variation to other indicators of disease activity, We examined the relationship of PEF variation, expressed in various ways, to symptoms, atopy, level of lung function, and airways hyperresponsiveness;ess in schoolchildren with asthma. One hundred and two asthmatic children (aged 7-14 yrs) recorded symptoms and PEF (twice daily) in a diary for 2 weeks after withdrawal of all anti-inflammatory maintenance medication, PEF variation was expressed as amplitude % mean, as standard deviation and coefficient of variation of all recordings, and as low % best (lowest PEF as percentage of the highest of all values). Atopy and level of forced expiratory volume in one second (FEV1) % predicted were not significantly related to PEF variation, The provocative dose of histamine causing a 20% fall in FEV1 (PD20) and symptom scores were significantly, but weakly, related to PEF variation, The index, low % best, proved easy to calculate and effective in identifying a short-term episode of reduced PEF. We conclude that peak expiratory flow variation in children with stable, moderately severe asthma is significantly, but weakly, related to symptoms and airways hyperresponsiveness, These three phenomena, therefore, all provide different information on the actual disease state, Expressing peak expiratory flow variation as low % best is easy to perform and appears to be clinically relevant.

The bronchodilator response (BDR) in forced expiratory volume in one second (FEV1) is routinely assessed to estimate the reversibility of airways obstruction. However, there is no consensus on how the BDR should be expressed, and recommendations applying to children are lacking. Similarly, the relationship between BDR and nonspecific bronchial hyperresponsiveness to histamine (BHR) has not been elucidated. These questions were addressed in 116 children, 7-16 yrs of age, with stable after withdrawal of all pulmonary maintenance medication. Inclusion criteria were an initial FEV1 between 55-90% predicted, and/or FEV1/forced vital capacity )FVC) between 50-75%, as well as a fall in FEV1 of 20% or more when challenged with up to 150 mug histamine. The change in FEV1 (DELTAFEV1) 20 min after inhalation of 800 mug salbutamol was expressed in four ways: as an absolute difference (DELTAV1(l)), as a percentage of predicted FEV1 (DELTAFEV1%pred) or initial FEV1 (DELTAFEV1%init), and as a percentage of the deficit in FEV, (DELTAFEV1%(pred-init)). DELTAFEV1%init and DELTAFEV1%pred were not related to age and stature of the children; DELTAFEV1%(pred-init) was related to stature, whilst DELTAFEV1(l) was related to both age and stature. All indices correlated with initial FEV1. However, this is an artefact introduced by relating change to initial value, rather than to the mean of initial and final value. In fact, BDR, expressed as DELTAFEV1%pred, was only slightly greater in children with the lowest initial airway calibre (p=0.08), unlike DELTAFEV1%init. BDR was weakly related to BHR. We conclude that the BDR in children is best expressed as DELTAFEV1%pred, because this is not dependent on age, stature and initial FEV1. In addition, BDR should not be taken as a measure of bronchial responsiveness to bronchoconstricting stimuli.

Background There is no agreement on how a bronchodilator response should be expressed. Ideally, the index used should be able to distinguish asthma from chronic obstructive lung disease and be independent of initial FEV1. Methods Two hundred and seventy four adult (aged 18-60 years) outpatients with obstructive airways disease were studied. Patients were divided into syndrome groups on the basis of a standardised history: asthma (n = 99), asthmatic bronchitis (n = 88), and chronic obstructive lung disease (n = 51); 36 subjects could not be attributed to any subgroup. FEV1 was measured before and 20 minutes after inhalation of 1000-mu-g terbutaline. Different expressions of bronchodilator response (DELTA-FEV1) were compared with respect to their dependence on initial FEV1 and their efficacy in separating subjects with asthma from those with chronic obstructive lung disease. DELTA-FEV1 was expressed as a percentage of initial FEV1 (DELTA-FEV1%init), absolute value (DELTA-FEV1[1]), percentage of predicted FEV1 (DELTA-FEV1%pred), standardised residual (DELTA-SR-FEV1), and percentage of maximal possible increase (DELTA-FEV1%[pred-init]). Results DELTA-FEV1%init was more dependent on initial FEV1 (rho = -0.405) than DELTA-FEV1[1] (r = -0.145), DELTA-FEV1%pred (r = -0.166), and DELTA-SR-FEV1 (r = -0.127). DELTA-FEV1%[pred-init] reached infinity when initial FEV1 approached predicted levels. DELTA-FEV1%pred had a higher likelihood ratio (1.71) for separating patients with asthma from those with chronic obstructive lung disease than other expressions of bronchodilator response. Asthmatic patients had larger mean bronchodilator responses than patients in other subgroups; this difference was largest for DELTA-SR-FEV1 (F = 9-19) and DELTA-FEV1%pred (F = 9.03); it was much smaller for DELTA-FEV1%init (F = 5-89). Despite significant differences in mean response, there was a large overlap of individual responses between diagnostic subgroups. The bronchodilator response was continuously and unimodally distributed for all expressions. Conclusions DELTA-FEV1%pred appears to be the most useful method of expressing bronchodilator response, both for clinical and for research purposes. Reversibility of airways obstruction in response to a bronchodilator is a continuous variable and not a dichotomous trait. Any cut off level of a "positive" bronchodilator response is therefore arbitrary.