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Lobectomy improves ventilatory function in selected
patients with severe COPD.
Korst RJ; Ginsberg RJ; Ailawadi M; Bains MS; Downey RJ Jr;
Rusch VW; Stover D
Department of Surgery, Memorial Sloan-Kettering Cancer
Center, New York, New York 10021, USA.
Ann Thorac Surg (United States) Sep 1998, 66 (3)
p898-902
BACKGROUND: Patients often undergo limited resection
instead of lobectomy for non-small cell lung cancer because of
a low preoperative forced expiratory volume in 1 second
(FEV1). Our goal is to define criteria that will
preoperatively identify a group of patients who will not lose
further function after lobectomy.
METHODS: Patients who underwent lobectomy with a
preoperative FEV1 of less than 80% of predicted were
retrospectively identified. Data collected included
preoperative and postoperative pulmonary function tests, age,
sex, the lobe resected, and preoperative ventilation-perfusion
scan result.
RESULTS: Thirty-two patients were included in this study.
The median preoperative FEV1 was 60% of predicted (1.65 L) and
the mean change in FEV1 was a loss of 7.8% after lobectomy.
The patients were divided into two groups. Group 1 (n = 13)
had a preoperative FEV1 of less than or equal to 60% of
predicted (median, 49%; 1.35 L) combined with an FEV1 to
forced vital capacity ratio of less than or equal to 0.6.
Group 2 (n = 19) includes all other patients (median
preoperative FEV1, 69% of predicted; 1.87 L). The mean changes
in FEV1 after lobectomy were +3.7% and -15.7% for groups 1 and
2, respectively (p < 0.005). A chronic obstructive
pulmonary disease index was defined and then calculated for
each patient. The relationship between this index and the
change in FEV1 after lobectomy for all 32 patients appears
linear (r = -0.43; p = 0.015).
CONCLUSIONS: Patients with a very low preoperative FEV1 and
FEV1 to forced vital capacity ratio are less likely to lose
ventilatory function after lobectomy and may actually improve
it.
Safety and cost-effectiveness of MIDCABG in
high-risk CABG patients.
Del Rizzo DF; Boyd WD; Novick RJ; McKenzie FN; Desai ND;
Menkis AH
London Health Sciences Centre, University of Western Ontario,
Canada.
ddelrizzo@exchange.hsc.mb.ca
Ann Thorac Surg (United States) Sep 1998, 66 (3)
p1002-7
BACKGROUND: Myocardial revascularization without
cardiopulmonary bypass has been proposed as a potential
therapeutic alternative in high-risk patients undergoing
coronary artery bypass grafting. To evaluate this possibility
we compared 15 high-risk (HR) patients in whom minimally
invasive direct coronary artery bypass grafting was used as
the method of revascularization with 41 consecutive patients
who underwent conventional coronary artery bypass grafting
during 1 month.
METHODS: Patients undergoing myocardial revascularization
without cardiopulmonary bypass were significantly older than
their low-risk (LR) counterparts (72.2 +/- 11.6 versus 63.3
+/- 9.7 years, p = 0.006). The demographic profile for HR
versus LR patients was as follows: female patients, 60.0%
versus 26.8%, p = 0.02; diabetes, 20.0% versus 24.4%, p = 0.7;
prior stroke, 33.3% versus 7.4%, p = 0.03; chronic obstructive
pulmonary disease, 60.0% versus 9.8%, p < 0.0001;
peripheral vascular disease, 33.3% versus 12.2%, p = 0.03,
congestive heart failure, 26.6% versus 9.8%, p = 0.09;
impaired left ventricular (ejection fraction < 0.40), 40.0%
versus 17.0%, p = 0.07; urgent operation, 86.6% versus 46.3%,
p < 0.0001; and redo operation, 20.0% versus 0%, p =
0.003.
RESULTS: There were no deaths in the HR group and one death
in the LR group. The average intensive care unit stay was 1.1
+/- 0.5 days in HR patients versus 1.6 +/- 1.6 days in LR
individuals (p = 0.2), and the average hospital stay was 6.1
+/- 1.8 versus 7.3 +/- 4.4 days, respectively (p = 0.3). We
used an acuity risk score index developed by the Adult Cardiac
Care Network of Ontario to predict outcome in the HR group.
The expected intensive care unit stay in HR patients was 4.1
+/- 1.2 days (versus the observed stay of 1.1 +/- 0.5 days, p
< 0.0001), and the expected hospital stay was 12.5 +/- 1.5
days (versus the observed stay of 6.1 +/- 1.8 days, p <
0.0001). The expected mortality in the HR group was 6.1%
versus 0%, p = 0.3. A cost regression model was used to
examine predicted versus actual cost (in Canadian dollars) for
the HR patient cohort (based on Ontario Ministry of Health
funding). The expected cost for the HR cohort would have been
$11,997 per patient. In contrast, the average cost for these
15 patients was $5,997 per patient, an estimated cost saving
of 50%.
CONCLUSIONS: Myocardial revascularization without
cardiopulmonary bypass appears to be a safe and cost-effective
therapeutic modality for HR patients requiring myocardial
revascularization.
The effects of nebulised isotonic saline and
terbutaline on breathlessness in severe chronic obstructive
pulmonary disease (COPD).
Poole PJ; Brodie SM; Stewart JM; Black PN
Department of Medicine, Faculty of Medicine and Health
Sciences, University of Auckland, NZ.
Aust N Z J Med (Australia) Jun 1998, 28 (3)
p322-6
BACKGROUND: There is anecdotal evidence that nebulised
saline relieves breathlessness at rest in patients with severe
chronic obstructive pulmonary disease (COPD). It is unclear
whether nebulised beta agonists are any more effective than
nebulised saline in relieving breathlessness at rest in these
individuals. AIM: To compare the effects of nebulised saline
and nebulised terbutaline on breathlessness at rest in
patients with severe COPD.
METHODS: We studied 18 patients with severe COPD with a
mean age of 71.1 years, forced expiratory volume in 1 second
(FEV1) of 0.58 L and vital capacity (VC) of 1.59 L, in a
randomised, double-blind, crossover trial. The subjects
received three doses of nebulised saline on one study day, and
three doses of nebulised terbutaline (cumulative dose 10 mg)
on the other. Breathlessness was measured using Likert and
Visual Analogue Scales (VAS).
RESULTS: Both treatments led to a significant improvement
in breathlessness on VAS and Likert scales but there was no
significant difference in breathlessness scores for saline
compared with terbutaline. There was a small but significant
increase in FEV1 with terbutaline of 74 mL, but no change with
saline.
CONCLUSIONS: A saline aerosol has no effect on lung
function but reduces breathlessness at rest in subjects with
severe COPD. Nebulised saline may be considered as an adjunct
to the use of nebulised bronchodilators for the treatment of
breathlessness in patients with COPD.
Effects of theophylline and ipratropium bromide on
exercise performance in patients with stable chronic
obstructive pulmonary disease.
Tsukino M; Nishimura K; Ikeda A; Hajiro T; Koyama H; Izumi
T
Chest Disease Research Institute, Kyoto University,
Japan.
Thorax (England) Apr 1998, 53 (4) p269-73
BACKGROUND: The effects of theophylline or anticholinergic
agents on exercise capacity in patients with chronic
obstructive pulmonary disease (COPD) remain controversial. The
aim of the present study was to compare the effect of an oral
theophylline with an inhaled anticholinergic agent and to
examine the effects of combined therapy on exercise
performance using progressive cycle ergometry.
METHODS: Twenty one men with stable COPD and a mean (SD)
forced expiratory volume in one second (FEV1) of 1.00 (0.40) 1
were studied. Theophylline (600 or 800 mg daily), ipratropium
bromide (160 micrograms), a combination of both drugs, and
placebo were given in a randomised, double blind, four period
crossover design study. Spirometric data, pulse rate, and
blood pressure were assessed before and at 90 and 120 minutes
after inhalation. Symptom limited progressive cycle ergometer
exercise tests (20 watts/min) were performed 90 minutes after
each inhalation, and dyspnoea was measured during exercise
using the Borg scale.
RESULTS: The mean (SD) serum theophylline concentration was
18.3 (6.3) micrograms/ml, and seven patients had side effects
during treatment with theophylline. Theophylline and
ipratropium bromide produced greater increases in FEV1,
maximal oxygen consumption, maximal minute ventilation, and
several dyspnoea ratios than placebo. There were no
differences between theophylline and ipratropium bromide
except in maximal heart rate. A combination of both drugs
produced greater improvements in pulmonary function and
exercise capacity than either drug alone.
CONCLUSIONS: Both high dose theophylline and high dose
ipratropium bromide improved exercise capacity in patients
with stable COPD. Although data based on short term effects
cannot be directly applied to long term therapy, theophylline
added to an inhaled anticholinergic agent may have beneficial
effects on exercise capacity in patients with COPD.
A multivariate model for predicting respiratory
status in patients with chronic obstructive pulmonary
disease.
Murata GH; Kapsner CO; Lium DJ; Busby HK
Veterans Affairs Medical Center, and the Department of
Medicine, University of New Mexico School of Medicine,
Albuquerque 87108, USA.
J Gen Intern Med (United States) Jul 1998, 13 (7)
p462-8
OBJECTIVE: To develop and validate a multivariate model for
predicting respiratory status in patients with advanced
chronic obstructive pulmonary disease (COPD).
DESIGN: Prospective, double-blind study of peak flow
monitoring.
SETTING: Albuquerque Veterans Affairs Medical Center.
PATIENTS: Male veterans with an irreversible component of
airflow obstruction on baseline pulmonary function tests.
MEASUREMENTS: This study was conducted between January 1995
and May 1996. At entry, subjects were instructed in the use of
the modified Medical Research Council Dyspnea Scale and a
mini-Wright peak flow meter equipped with electronic storage.
For the next 6 months, they recorded their dyspnea scores once
daily and peak expiratory flow rates twice daily, before and
after the use of bronchodilators. Patients were blinded to
their peak expiratory flow rates, and medical care was
provided in the customary manner. Readings were aggregated
into 7-day sampling intervals, and interval means were
calculated for dyspnea score and peak expiratory flow rate
parameters. Intervals from all subjects were then pooled and
randomized to separate groups for model development (training
set) and validation (test set). In the training set, logistic
regression was used to identify variables that predicted
future respiratory status. The dependent variable was the log
odds that the subject would attain his highest level of
dyspnea in the next 7 days. The final model was used to
stratify the test set into "high-risk" and "low-risk"
categories. The analysis was repeated for 3-day intervals.
MAIN RESULTS: Of the 40 patients considered eligible for
study, 8 declined to participate, 4 could not master the
technique of peak flow monitoring, and 6 had no fluctuations
in their dyspnea level. The remaining 22 subjects form the
basis of this report. Fourteen (64%) of the latter completed
the 6-month protocol. Data from the 8 who were dropped or died
were included up to the point of withdrawal. For 7-day
forecasts, mean dyspnea score and mean daily prebronchodilator
peak expiratory flow rate were identified as predictor
variables. The adjusted odds ratio (OR) for mean dyspnea score
was 2.71 (95% confidence interval [CI] 1.79, 4.12) per unit.
For mean prebronchodilator peak expiratory flow rate, it was
1.05 (95% CI 1.01, 1.09) per percentage predicted. For 3-day
forecasts, the model was composed of mean dyspnea score and
mean daily bronchodilator response. The ORs for these terms
were 2.66 (95% CI 2.06, 3.44) per unit and 0.980 (95% CI
0.962, 0.998) per percentage of improvement over baseline,
respectively. For a given level of dyspnea, higher
pre-bronchodilator peak expiratory flow rate and lower
bronchodilator response were poor prognostic findings. When
the models were applied to the test sets, "high-risk"
intervals were 4 times more likely to be followed by maximal
symptoms than "low-risk" intervals.
CONCLUSIONS: Dyspnea scores and certain peak expiratory
flow rate parameters are independent predictors of respiratory
status in patients with COPD. However, our results suggest
that monitoring is of little benefit except in patients with
the most advanced form of this disease, and its contribution
to their management is modest at best.
Using nasal intermittent positive pressure
ventilation on a general respiratory ward.
Brown JS; Meecham Jones DJ; Mikelsons C; Paul EA; Wedzicha
JA
Department of Respiratory Medicine, London Chest
Hospital.
J R Coll Physicians Lond (England) May-Jun 1998, 32 (3)
p219-24
OBJECTIVES: To assess the use of nasal intermittent
positive pressure ventilation (NIPPV) in treating
acute-on-chronic respiratory failure in a general medical
ward.
DESIGN: Retrospective analysis of clinical outcome.
SETTING: A general medical ward of a tertiary respiratory
medicine referral centre.
SUBJECTS: Altogether 75 patients admitted with acute
exacerbations of chronic respiratory failure and treated
NIPPV.
MAIN OUTCOME MEASURES: Blood gas tensions determined at
admission to hospital and during NIPPV, tolerance of NIPPV and
mortality.
RESULTS: During treatment with NIPPV, the mean (SD) PaO2
increased rapidly by 2.31 (3.58) kPa (p < 0.0001), while
the mean PaCO2 fell by 1.07 (1.74) kPa (p < 0.0001) and the
mean pH increased by 0.03 (0.07) (p = 0.001). Altogether 57
(76%) of patients tolerated NIPPV, and (9.3%) died in
hospital. Improvement in PaO2 was more noticeable in patients
with chronic obstructive pulmonary disease (+3.13 (3.49) kPa,
p < 0.0001) than in those with restrictive chest wall
disease (+1.20 (3.07) kPa, p = 0.25) or obstructive sleep
apnoea (+0.18 (3.64), p = 0.88). The reduction in PaCO2 was
similar in all three groups.
CONCLUSIONS: In routine treatment of unselected patients
with acute-on-chronic respiratory failure who are being cared
for on a general ward, NIPPV rapidly improves hypoxaemia and
hypercapnia, is well tolerated and is associated with low
mortality.
Determination of functional residual capacity (FRC)
by multibreath nitrogen washout in a lung model and in
mechanically ventilated patients. Accuracy depends on
continuous dynamic compensation for changes of gas sampling
delay time.
Wrigge H; Sydow M; Zinserling J; Neumann P; Hinz J; Burchardi
H
Zentrum Anaesthesiologie, Rettungs- u. Intensivmedizin,
Gottingen, Germany.
hwrigge@gwdg.de
Intensive Care Med (United States) May 1998, 24 (5)
p487-93
OBJECTIVE: Validation of an open-circuit multibreath
nitrogen washout technique (MBNW) for measurement of
functional residual capacity (FRC). The accuracy of FRC
measurement with and without continuous viscosity correction
of mass spectrometer delay time (TD) relative to gas flow
signal and the influence of baseline FIO2 was
investigated.
DESIGN: Laboratory study and measurements in mechanically
ventilated patients.
SETTING: Experimental laboratory and anesthesiological
intensive care unit of a university hospital.
PATIENTS: 16 postoperative patients with normal pulmonary
function (NORM), 8 patients with acute lung injury (ALI) and 6
patients with chronic obstructive pulmonary disease (COPD)
were included.
INTERVENTIONS: Change of FIO2 from baseline to 1.0.
MEASUREMENTS AND MAIN RESULTS: FRC was determined by MBNW
using continuous viscosity correction of TD(TDdyn), a constant
TD based on the viscosity of a calibration gas mixture (TD0)
and a constant TD referring to the mean viscosity between
onset and end of MBNW (TDmean). Using TDdyn, the mean
deviation between 15 measurements of three different lung
model FRCs (FRCmeasured) and absolute volumes (FRCmodel) was
0.2%. For baseline FIO2 ranging from 0.21 to 0.8, the mean
deviation between FRCmeasured and FRCmodel was -0.8%. However,
depending on baseline FIO2, the calculation of FRC using
TDmean and TD0 increased the mean deviation between
FRCmeasured and FRCmodel to 2-4% and 8-12%, respectively. In
patients (n = 30) the average repeatability coefficient was
6.0%. FRC determinations with TDmean and TD0 were 0.8-13.3%
and 4.2-23.9% (median 2.7% and 8.7%) smaller than those
calculated with TDdyn.
CONCLUSION: A dynamic viscosity correction of TD improves
the accuracy of FRC determinations by MBNW considerably, when
gas concentrations are measured in a sidestream. If dynamic TD
correction cannot be performed, the use of constant TDmean
might be suitable. However, in patient measurements this can
cause an FRC underestimation of up to 13%.
[Knowledge about drugs used by adult patients with
asthma for self-treatment]
Klein JJ; van der Palen J; Seydel ER; Kerkhoff AH
Medisch Spectrum Twente, afd. Longziekten, Enschede.
Ned Tijdschr Geneeskd (Netherlands) Mar 28 1998, 142 (13)
p711-5
OBJECTIVE: To assess the knowledge of adult asthmatics
about medication for self-treatment.
DESIGN: Descriptive.
SETTING: Department of Pulmonary Diseases, Medisch Spectrum
Twente, Enschede, the Netherlands.
METHODS: As a part of a larger project aimed at improvement
of self-management and self-treatment, all adults aged 18-65
years in Enschede (population 146,000) reported by the city
pharmacists as using medication for asthma or chronic
obstructive pulmonary disease, in 1994 were sent a
questionnaire including 7 items pertaining to knowledge about
lung medication. From among those who failed to respond after
a written reminder and an appeal in local papers, a random
group of 9% were interviewed by telephone. Of the responders
who reported that according to their GPs they had asthma and
who had answered the questions on medication, the number of
questions answered correctly was counted; in addition, the
question was investigated whether their level of knowledge was
related to sex, education, use of (inhalation) corticosteroids
and the form of explanation received.
RESULTS: A total of 4563 questionnaires were sent out: 2259
(50%) usable forms were returned. The responders were better
educated than the 192 non-responders interviewed, but did not
differ as to age or sex. Of the responders, 1262 (56%)
reported that their GPs had told them they had asthma. On
average they had answered 2.4 (range: 0-7) out of 7 questions
correctly. Previous instruction, number of sources of
information, duration of taking medication, use of inhaled
steroids, female sex and better education were all positively
related with a higher knowledge score in this group.
CONCLUSION: Adult asthmatics did not have sufficient
knowledge about their medication. Improving such knowledge
should therefore be an important element in the development of
a self-management programme.
No effects of high-dose omeprazole in patients with
severe airway hyperresponsiveness and (a)symptomatic
gastro-oesophageal reflux.
Boeree MJ; Peters FT; Postma DS; Kleibeuker JH
Dept of Pulmonary Medicine, University Hospital, Groningen,
The Netherlands.
Eur Respir J (Denmark) May 1998, 11 (5) p1070-4
Acid gastro-oesophageal reflux may aggravate respiratory
symptoms in patients with asthma and chronic obstructive
pulmonary disease (COPD) by increasing airway
hyperresponsiveness through vagally-mediated pathways. We
wanted to determine whether elimination of acid reflux could
improve symptoms in such patients. In a randomized,
double-blind, placebo-controlled study, 36 allergic and
nonallergic subjects (17 males and 19 females, mean age 52
yrs), with airway obstruction and severe airway
hyperresponsiveness despite maintenance treatment with an
inhaled corticosteroid and with increased acid
gastro-oesophageal reflux, were treated either with
omeprazole, 40 mg b.i.d., or placebo for 3 months. Primary
endpoints were: airway hyperresponsiveness, as determined by
the provocative concentration of methacholine producing a 20%
fall in forced expiratory volume in one second (PC20); and
airway obstruction. Secondary endpoints were: peak expiratory
flow variability; reversibility to inhaled ipratropium bromide
as a parameter of vagal activity; asthma symptoms scores; and
medication used. Reflux was measured by 24 h ambulatory
intraoesophageal pH measurement. Omeprazole, 40 mg b.i.d., for
3 months had no beneficial effect on any of the pulmonary
parameters, despite its profound effect on acid reflux and
improvement of reflux symptoms scores, compared to placebo.
The results of this study do not support a role for intensive
antireflux therapy to improve pulmonary symptoms and function
in patients with asthma and chronic obstructive pulmonary
disease, who have severe airway hyperresponsiveness despite
maintenance treatment with inhaled corticosteroids.
Domiciliary nocturnal intermittent positive
pressure ventilation in patients with respiratory failure due
to severe COPD: long-term follow up and effect on
survival.
Jones SE; Packham S; Hebden M; Smith AP
Chest Department, Llandough Hospital & Community NHS
Trust, Penarth, South Glamorgan, UK.
Thorax (England) Jun 1998, 53 (6) p495-8
BACKGROUND: There is increasing interest in the use of
non-invasive nocturnal intermittent positive pressure
ventilation (NIPPV) in the management of patients with chronic
hypercapnoeic (type II) respiratory failure. Although this
treatment enables patients requiring mechanical ventilatory
support to the treated more readily at home, few studies have
been done to demonstrate its long term benefits in chronic
obstructive pulmonary disease (COPD) and the application of
NIPPV in these circumstances remains controversial.
METHODS: Eleven patients in severe stable chronic type II
respiratory failure due to COPD who were unresponsive to
conventional treatments experienced symptomatic hypercapnia
when receiving sufficient supplementary oxygen to result in an
arterial oxygen saturation (SaO2) of > 90%. They were
assessed for treatment with NIPPV, and its effects were
observed for over two years using arterial blood gas tensions,
spirometric parameters and body mass index (BMI), survival,
hospital admissions, use of general practitioner resources,
and patient satisfaction.
RESULTS: Hospital admissions and GP consultations were
halved after one year compared with the year before NIPPV and
there was a sustained improvement in arterial blood gas
tensions at 12 and 24 months when breathing air, despite
progressive deterioration in ventilatory function. BMI did not
change during the period of observation. The median survival
was 920 days, with no patient dying within the first 500
days.
CONCLUSIONS: Domiciliary NIPPV results in improvements in
arterial blood gas tensions which are sustained after two
years of treatment and reduces both hospital admissions and
general practitioner visits by patients with severe COPD in
hypercapnoeic respiratory failure. It is well tolerated and,
although there was no control group, survival appears to be
prolonged when these results are compared with those of the
NOTT and MRC (LTOT) trials.
Randomised controlled trial of inhaled
corticosteroids in patients with chronic obstructive pulmonary
disease.
Bourbeau J; Rouleau MY; Boucher S
McGill University Health Centre, McGill University, Montreal,
Canada.
Thorax (England) Jun 1998, 53 (6) p477-82
BACKGROUND: Inhaled corticosteroids are known to be
beneficial for patients with asthma, but their role in
treating patients with stable chronic obstructive pulmonary
disease (COPD) remains controversial. A study was undertaken
to determine whether inhaled corticosteroids are of functional
benefit in patients who did not show improvement with a trial
of oral corticosteroids.
METHODS: In phase I patients with stable COPD were given a
two week course of oral placebo followed by two weeks of
prednisone 40 mg per day in a single blind manner to
distinguish between responders and non-responders to oral
corticosteroids. In phase II a double blind, randomised,
parallel group trial of inhaled budesonide 1600 micrograms per
day versus placebo was carried out in 79 nonresponders to oral
corticosteroids. The primary outcome measure was forced
expiratory volume in one second (FEV1), and secondary outcome
measures were exercise capacity, dyspnoea with exertion,
quality of life, peak expiration flow rate, and respiratory
symptoms.
RESULTS: Randomisation allocated 39 subjects to inhaled
corticosteroids and 40 to placebo. There was no difference in
the change in FEV1 from baseline between the treatment and
placebo groups; mean difference -12 ml (95% CI -88 to 63) at
three months and -4 ml (95% CI -95 to 87) at six months. The
proportion of patients with a 15% or greater improvement was
no higher among those receiving inhaled corticosteroids than
in the placebo group at any of the follow up visits. Changes
in secondary outcomes were also no different.
CONCLUSIONS: Inhaled corticosteroids, even at high doses,
were of no physiological or functional benefit in these
patients with advanced COPD.
Effect of beta-blockade on mortality among
high-risk and low-risk patients after myocardial
infarctio
Gottlieb SS; McCarter RJ; Vogel RA
Department of Medicine, University of Maryland School of
Medicine, Baltimore, USA.
N Engl J Med (United States) Aug 20 1998, 339 (8)
p489-97
BACKGROUND: Long-term administration of beta-adrenergic
blockers to patients after myocardial infarction improves
survival. However, physicians are reluctant to administer
beta-blockers to many patients, such as older patients and
those with chronic pulmonary disease, left ventricular
dysfunction, or non-Q-wave myocardial infarction.
METHODS: The medical records of 201,752 patients with
myocardial infarction were abstracted by the Cooperative
Cardiovascular Project, which was sponsored by the Health Care
Financing Administration. Using a Cox proportional-hazards
model that accounted for multiple factors that might influence
survival, we compared mortality among patients treated with
beta-blockers with mortality among untreated patients during
the two years after myocardial infarction.
RESULTS: A total of 34 percent of the patients received
beta-blockers. The percentage was lower among the very
elderly, blacks, and patients with the lowest ejection
fractions, heart failure, chronic obstructive pulmonary
disease, elevated serum creatinine concentrations, or type 1
diabetes mellitus. Nevertheless, mortality was lower in every
subgroup of patients treated with beta-blockade than in
untreated patients. In patients with myocardial infarction and
no other complications, treatment with beta-blockers was
associated with a 40 percent reduction in mortality. Mortality
was also reduced by 40 percent in patients with non-Q-wave
infarction and those with chronic obstructive pulmonary
disease . Blacks, patients 80 years old or older, and those
with a left ventricular ejection fraction below 20 percent,
serum creatinine concentration greater than 1.4 mg per
deciliter (124 micromol per liter), or diabetes mellitus had a
lower percentage reduction in mortality. Given, however, the
higher mortality rates in these subgroups, the absolute
reduction in mortality was similar to or greater than that
among patients with no specific risk factors.
CONCLUSIONS: After myocardial infarction, patients with
conditions that are often considered contraindications to
beta-blockade (such as heart failure, pulmonary disease, and
older age) and those with nontransmural infarction benefit
from beta-blocker therapy.
Rehabilitation of patients admitted to a
respiratory intensive care unit.
Nava S
Respiratory Intensive Care Unit, Centro Medico di Montescano,
S. Maugeri Foundation, Italy.
Arch Phys Med Rehabil (United States) Jul 1998, 79 (7)
p849-54
OBJECTIVE: Pulmonary rehabilitation has been shown to be of
benefit to clinically stable patients with chronic obstructive
pulmonary disease (COPD). This study examined the effect of
pulmonary rehabilitation on some physiologic variables in COPD
patients recovering from an episode of acute respiratory
failure.
DESIGN: A prospective, randomized study.
SETTING: A respiratory intensive care unit (RICU).
PATIENTS: Eighty COPD patients recovering from an episode
of acute respiratory failure were randomized in a 3:1 fashion
to receive stepwise pulmonary rehabilitation (group A, n=60
patients) or standard medical therapy (group B, n=20
patients).
MAIN OUTCOME MEASURES: Improvements in exercise tolerance,
sense of breathlessness, respiratory muscle function, and
pulmonary function test values were measured, respectively, by
exercise capacity (6-minute walking distance [6MWD]), dyspnea
score (Visual Analog Scale [VAS]), maximal inspiratory
pressure (MIP), forced expiratory volume in 1 second (FEV1),
and forced vital capacity (FVC).
INTERVENTIONS: Group A received pulmonary rehabilitation
that consisted of passive mobilization (step I), early
deambulation (step II), respiratory and lower skeletal muscle
training (step III), and if the patients were able, complete
lower extremity training on a treadmill (step IV). Group B
received standard medical therapy plus a basic deambulation
program.
RESULTS: Sixty-one of 80 patients were mechanically
ventilated at admission to the unit and most of them were
bedridden. Twelve of the 60 group A patients and 4 of the 20
group B patients died during their RICU stay, and 9 patients
required invasive mechanical ventilation at home after their
discharge. The total length of RICU stay was 38+/-14 days for
patients in group A versus 33.2+/-11 days for those in group
B. Most patients from both groups regained the ability to
walk, either unaided or aided. At discharge, 6 MWD results
were significantly improved (p < .001) in Group A only. MIP
improved in Group A only (p < .05), while VAS scores
improved in both groups, but the improvement was more marked
in group A (p < .001) than in group B (p < .05).
CONCLUSIONS: COPD patients who were admitted to a RICU in
critical condition after an episode of acute respiratory
failure and who, in most cases, required mechanical
ventilation benefited from comprehensive early pulmonary
rehabilitation, compared with patients who received standard
medical therapy and progressive ambulation.
TQI in the Albuquerque Veterans Affairs Medical
Center's long-term oxygen therapy program.
Montner P; Sergent M; Case E; Douglas M; Griego E; Martinez
F; Jaramillo B; Tarasenko P
Pulmonary Section, Albuquerque Veterans Affairs Medical
Center, NM, USA.
Jt Comm J Qual Improv (United States) Apr 1998, 24 (4)
p203-11
BACKGROUND: Long-term oxygen therapy (LTOT) is the only
treatment demonstrated to prolong the life of patients with
chronic obstructive pulmonary disease . In November 1994, a
multidisciplinary total quality improvement (TQI) team
composed of the involved hospital services was established to
reorganize and improve the LTOT program at the Albuquerque
Veterans Affairs Medical Center (AVAMC), Albuquerque.
FROM THE OLD TO THE NEW PROCESS: The LTOT team used a
process map to analyze the current process and gather
information from patients and staff regarding their
satisfaction with the program. It then began working on the
identified problems and streamlining the LTOT referral
process. A respiratory therapy position with the specific
responsibility of serving as the home oxygen (O2) coordinator
(HOC) was established and filled. The evaluation process was
to be initiated by the AVAMC physicians, following which the
HOC would perform a newly standardized evaluation that would
establish the patient's need for O2 and result in a specific
prescription.
RESULTS: Quality indicators were selected to monitor
changes in the program. Data from chart reviews, the Veterans
Affairs National Cost Containment Center, and patient surveys
were used to evaluate the indicators. Timeliness of referral
to the program before inpatient discharge improved, O2
prescriptions in the new program more frequently addressed
activity, and the cost per patient was reduced by 37.1%.
Patient satisfaction rates also improved .
DISCUSSION: A motivated team with representatives of the
services involved was able to analyze and dramatically improve
an important but complicated program.
The need for acute, subacute and nonacute care at
105 general hospital sites in Ontario. Joint Policy and
Planning Committee Non-Acute Hospitalization Project Working
Group.
Flintoft VF; Williams JI; Williams RC; Basinski AS;
Blackstien-Hirsch P; Naylor CD
Institute for Clinical Evaluative Sciences, Toronto,
Ont.
CMAJ (Canada) May 19 1998, 158 (10) p1289-96
BACKGROUND: Previous studies of hospital utilization have
not taken into account the use of acute care beds for subacute
care. The authors determined the proportion of patients who
required acute, subacute and nonacute care on admission and
during their hospital stay in general hospitals in Ontario.
From this analysis, they identified areas where the efficiency
of care delivery might be improved .
METHODS: Ninety-eight of 189 acute care hospitals in
Ontario, at 105 sites, participated in a review that used
explicit criteria for rating acuity developed by Inter-Qual
Inc., Marlborough, Mass. The records of 13,242 patients who
were discharged over a 9-month period in 1995 after hospital
care for 1 of 8 high-volume, high-variability diagnoses or
procedures were randomly selected for review. Patients were
categorized on the basis of the level of care (acute, subacute
or nonacute) they required on admission and during subsequent
days of hospital care.
RESULTS: Of all admissions, 62.2% were acute, 19.7%
subacute and 18.1% nonacute. The patients most likely to
require acute care on admission were those with acute
myocardial infarction (96.2% of 1826 patients) or
cerebrovascular accident (84.0% of 1596 patients) and those
admitted for elective surgery on the day of their procedure
(73.4% of 3993 patients). However, 41.1% of patients awaiting
hip or knee replacement were admitted the day before surgery
so did not require acute care on admission. The proportion of
patients who required acute care on admission and during the
subsequent hospital stay declined with age; the proportion of
patients needing nonacute care did not vary with age. After
admission, acute care was needed on 27.5% of subsequent days,
subacute care on 40.2% and nonacute care on 32.3%. The need
for acute care on admission was a predictor of need for acute
care during subsequent hospital stay among patients with
medical conditions. The proportion of patients requiring
subacute care during the subsequent hospital stay increased
with age, decreased with the number of inpatient beds in each
hospital and was highest among patients with congestive heart
failure, chronic obstructive pulmonary disease and
pneumonia.
INTERPRETATION: In 1995, inpatients requiring subacute care
accounted for a substantial proportion of nonacute care days
in Ontario's general hospitals. These findings suggest a need
to evaluate the efficiencies that might be achieved by
introducing a subacute category of care into the Canadian
health care system. Generally, efforts are needed to reduce
the proportion of admissions for nonacute care and of
in-hospital days for other than acute care.
Pubovaginal sling using polypropylene mesh and
Vesica bone anchors.
Hom D; Desautel MG; Lumerman JH; Feraren RE; Badlani GH
Department of Urology, Long Island Jewish Medical Center, New
Hyde Park, New York 11040, USA.
Urology (United States) May 1998, 51 (5) p708-13
OBJECTIVES: To report preliminary results from a modified
pubovaginal sling procedure using polypropylene mesh as the
sling suspended by nonabsorbable sutures anchored to the pubic
tubercle with Vesica bone anchors.
METHODS: Thirty-five women with type III stress urinary
incontinence (SUI) (with or without associated urethral
hypermobility) or type II SUI with additional risk factors
such as obesity, chronic obstructive pulmonary disease, or
failed prior incontinence-correcting procedures underwent this
modified pubovaginal sling procedure. Postoperative voiding
status was evaluated during office follow-up visits and
telephone surveys.
RESULTS: With a mean follow-up of 8.4 months (range 2 to
18), 32 women (91.4%) were dry, 1 improved, and 2 remained
incontinent. The pubovaginal sling procedure was the only
operation performed in 46% of patients, with a mean operative
time of 72 minutes, a mean estimated blood loss of 137 mL, and
a mean hospital period of 2.3 days. Patients on whom
concomitant gynecologic procedures were performed had a mean
duration of surgery of 122 minutes, a mean estimated blood
loss of 202 mL, and a mean hospitalization period of 2.9 days.
Thirteen women had preoperative urgency that persisted in 31%
of patients. De novo urgency developed in 3 patients. Seven
women required prolonged suprapubic tube drainage but no
patient remained in permanent retention. There has been no
infection or erosion.
CONCLUSIONS: Our experience with this modified pubovaginal
sling procedure using polypropylene mesh and Vesica bone
anchors showed excellent results with greater technical ease,
minimal morbidity, and decreased hospitalization period when
compared to a traditional pubovaginal sling performed in our
hands. Additional follow-up will be needed to assess long-term
efficacy.
The self-inflating bulb to detect esophageal
intubation during emergency airway management.
Kasper CL; Deem S
Respiratory Care Department, Harborview Medical Center,
Seattle, Washington 98104-2499, USA.
ckasper@u.washington.edu
Anesthesiology (United States) Apr 1998, 88 (4)
p898-902
BACKGROUND: The negative-pressure test using a
self-inflating bulb (SIB) during emergency intubation was
studied to determine its reliability and predictive value in
this setting.
METHODS: The endotracheal tube (ETT) position was tested in
300 consecutive patients undergoing in-hospital emergency
endotracheal intubation. Immediately after intubation and
before ETT cuff inflation, the following protocol was strictly
followed: (1) an SIB was compressed, connected to the ETT, and
released. A 10-s period was allowed for the bulb to inflate.
(2) The ETT cuff was inflated, and the ETT position was
confirmed using colorimetric or infrared carbon dioxide
detection, or both, combined with clinical evaluation.
RESULTS: There were 19 esophageal intubations (6%
incidence). The SIB correctly identified all patients with
esophageal intubation (sensitivity, 100%) and correctly
identified all but three ETTs placed in the trachea
(specificity, 99%). The three tracheally placed tubes that
were misidentified by the bulb syringe occurred during one
case each of chronic obstructive pulmonary disease, copious
secretions, and obesity; of note were three tracheally placed
tubes that were misidentified by the carbon dioxide analyzers
during cardiopulmonary resuscitation.
CONCLUSIONS: The SIB proved to be a sensitive and specific
test for esophageal intubation in the emergency setting when
used according to the protocol described, and it is
complementary to carbon dioxide detection. The predictive
value of the bulb syringe appears to be improved when a
prolonged period for reinflation is allowed. It holds
particular promise because of its low cost and
portability.
Effects of specialized community nursing care in
patients with chronic obstructive pulmonary disease.
Ketelaars CA; Huyer Abu-Saad H; Halfens RJ; Schlosser MA;
Mostert R; Wouters EF
Department of Nursing Science, University of Limburg,
Maastricht, The Netherlands.
Heart Lung (United States) Mar-Apr 1998, 27 (2)
p109-20
OBJECTIVE: To investigate the effects of specialized
respiratory home nursing care after discharge from a pulmonary
rehabilitation center.
DESIGN: Pretest-posttest control group design. Patients in
the experimental group were visited by a nurse who specializes
in respiratory care, whereas the control group received care
from nurses who did not specialize in respiratory care.
SETTING: Data were collected on admission, at program
discharge, and 4 months and 9 months after discharge from a
pulmonary rehabilitation center.
PATIENTS: One hundred fifteen patients were included in the
study and observed for 1 year.
OUTCOME MEASURES: Health-related quality of life (HRQL),
coping strategies, compliance, hospitalization, and
satisfaction with the care provided.
RESULTS: Complete data sets were obtained from 78 patients
with severe airflow obstruction (FEV1 = 41%; predicted +/- SD
= 15). Corrections were made for the selective nonresponse,
but did not lead to adjustments in outcome scores. In both
groups, HRQL scores improved between admission and discharge,
but deteriorated 4 months and 9 months after discharge. The
only statistically significant short-term effect was found on
the "activities" component of HRQL in favor of the control
group. No differences were found between groups regarding
coping, compliance, and hospitalization. Patients in the
experimental group, however, were more satisfied with the care
provided by the specialized community nurses.
CONCLUSIONS: The treatment intervention of specialized
respiratory home nursing might not have been specific or
intensive enough to result in outcome benefits . Secondly, the
initial benefits from baseline pulmonary rehabilitation alone
may have led to positive outcomes in both patient groups.
Development of a shortened version of the Breathing
Problems Questionnaire suitable for use in a pulmonary
rehabilitation clinic: a purpose-specific, disease-specific
questionnaire.
Hyland ME; Singh SJ; Sodergren SC; Morgan MP
Department of Psychology, University of Plymouth, UK.
mhyland@plymouth.ac.uk
Qual Life Res (England) Apr 1998, 7 (3) p227-33
One hundred and thirty-eight chronic obstructive pulmonary
disease (COPD) patients completed the Breathing Problems
Questionnaire (BPQ) before and after a comprehensive programme
of rehabilitation. Examination of the changes on individual
items showed improvement on 22 items, of which four items were
significant at p < 0.05 and deterioration on nine items, of
which two were significant at p < 0.01. All deteriorating
items were consistent with lifestyle adaptations encouraged as
part of the rehabilitation programme. We examined the
psychometric properties of a reduced ten item version of the
BPQ limited to the items most sensitive to change. We
recommend the purpose-specific, disease-specific COPD scale
for measuring change in pulmonary rehabilitation assessment in
contrast to the longer 33 item questionnaire, which, however,
may be more useful for cross-sectional assessment.
Independent association between acute renal failure
and mortality following cardiac surgery.
Chertow GM; Levy EM; Hammermeister KE; Grover F; Daley
J
Department of Medicine, Brigham and Women's Hospital, Boston,
Massachusetts 02115, USA.
Am J Med (United States) Apr 1998, 104 (4)
p343-8
PURPOSE: To determine whether there is an independent
association of acute renal failure requiring dialysis with
operative mortality after cardiac surgery.
PATIENTS AND METHODS: The 42,773 patients who underwent
coronary artery bypass or valvular heart surgery at 43
Department of Veterans Affairs Medical Centers between 1987
and 1994 were evaluated to determine the association between
acute renal failure sufficient to require dialysis and
operative mortality, with and without adjustment for
comorbidity and postoperative complications. Crude and
adjusted odds ratios (OR) and 95% confidence intervals (95%
CI) were derived from logistic regression analysis.
RESULTS: Acute renal failure occurred in 460 (1.1%)
patients. Overall operative mortality was 63.7% in these
patients, compared with 4.3% in patients without this
complication. The unadjusted OR for death was 39 (95% CI 32 to
48). After adjustment for comorbid factors related to the
development of acute renal failure (surgery type, baseline
renal function, preoperative intraaortic balloon pump, prior
heart surgery, NYHA class IV status, peripheral vascular
disease, pulmonary rales, left ventricular ejection fraction
below 35%, chronic obstructive pulmonary disease, systolic
blood pressure, and the cross-product of systolic blood
pressure and surgery type), the OR was 27 (95% CI 22 to 34).
Further adjustment was made for seven postoperative
complications (low cardiac output, cardiac arrest,
perioperative myocardial infarction, prolonged mechanical
ventilation, reoperation for bleeding or repeat
cardiopulmonary bypass, stroke or coma, and mediastinitis),
that were independently associated with operative mortality.
The OR adjusted for comorbidity and postoperative
complications associated with acute renal failure was 7.9 (95%
CI 6 to 10).
CONCLUSIONS: Acute renal failure was independently
associated with early mortality following cardiac surgery,
even after adjustment for comorbidity and postoperative
complications. Interventions to prevent or improve treatment
of this condition are urgently needed.
Multicenter review of preoperative risk factors for
endarterectomy for asymptomatic carotid artery stenosis.
Goldstein LB; Samsa GP; Matchar DB; Oddone EZ
Center for Clinical Health Policy Research, Division of
Neurology, Duke University, Department of Veterans Affairs
Medical Center, Durham, NC, USA.
golds004@mc.duke.edu
Stroke (United States) Apr 1998, 29 (4) p750-3
BACKGROUND AND PURPOSE: The benefit of carotid
endarterectomy is highly dependent on surgical risk. However,
little data are available concerning factors affecting the
risk of endarterectomy performed for asymptomatic carotid
artery stenosis outside the setting of a randomized controlled
trial. The purpose of this study was to analyze the impact of
potential preoperative risk factors on the frequency of
postoperative complications in patients undergoing the
operation for asymptomatic disease in academic medical
centers.
METHODS: Data regarding postoperative complications were
systematically abstracted from the medical records of a random
sample of patients who underwent carotid endarterectomy at 12
academic medical centers.
RESULTS: Of 1160 procedures reviewed, 463 (40%) were
performed for asymptomatic disease. Postoperative stroke or
death occurred in 13 (2.8%), and myocardial infarction
occurred in 8 (1.7%). The rate of postoperative stroke or
death was lower in asymptomatic patients than in those with a
history of cerebrovascular symptoms in a different vascular
distribution, but the difference was not significant (1.8%
versus 4.2%; P=.21). There were no significant differences in
these rates based on race, a history of angina, recent
myocardial infarction, chronic obstructive pulmonary disease,
hypertension, the degree of stenosis of the contralateral or
ipsilateral carotid artery, or the presence of
angiographically recognized ulceration, intraluminal thrombus,
or siphon stenosis in the ipsilateral vessel (chi(2);
P>.05). Postoperative stroke or death was more frequent in
women (5.3% versus 1.6% in men; P=.02), in those aged 75 years
or older (7.8% versus 1.8% in those younger than 75 years;
P=.01), and in those with a history of congestive heart
failure (8.6% versus 2.3% in those without a history of
congestive heart failure; P=.03). The risk of stroke or death
was higher in the 16 patients who had carotid endarterectomy
performed in combination with coronary artery bypass surgery
than in those who had only endarterectomy (18.7% versus 2.1%;
P<.001).
CONCLUSIONS: The overall risk of postoperative stroke or
death was nearly twice that reported by Asymptomatic Carotid
Atherosclerosis Study (ACAS) investigators in the setting of a
clinical trial but was within acceptable guidelines. Women
were at higher postoperative risk than men, which supported
ACAS findings. Additional high-risk groups were those aged 75
years or older, those with a history of congestive heart
failure, and those undergoing prophylactic endarterectomy for
asymptomatic stenosis in combination with coronary surgery.
Knowledge of these rates may help to better assess an
individual's postoperative risk and therefore the anticipated
benefit of surgery.
Noninvasive mechanical ventilation in the weaning
of patients with respiratory failure due to chronic
obstructive pulmonary disease. A randomized, controlled
trial.
Nava S; Ambrosino N; Clini E; Prato M; Orlando G; Vitacca M;
Brigada P; Fracchia C; Rubini F
Centro Medico di Riabilitazione di Montescano, Italy.
Ann Intern Med (United States) May 1 1998, 128 (9)
p721-8
BACKGROUND: In patients with acute exacerbations of chronic
obstructive pulmonary disease, mechanical ventilation is often
needed. The rate of weaning failure is high in these patients,
and prolonged mechanical ventilation increases
intubation-associated complications.
OBJECTIVE: To determine whether noninvasive ventilation
improves the outcome of weaning from invasive mechanical
ventilation.
DESIGN: Multicenter, randomized trial.
SETTING: Three respiratory intensive care units. PATIENTS:
Intubated patients with chronic obstructive pulmonary disease
and acute hypercapnic respiratory failure.
INTERVENTION: A T-piece weaning trial was attempted 48
hours after intubation. If this failed, two methods of weaning
were compared: 1) extubation and application of noninvasive
pressure support ventilation by face mask and 2) invasive
pressure support ventilation by an endotracheal tube.
MEASUREMENTS: Arterial blood gases, duration of mechanical
ventilation, time in the intensive care unit, occurrence of
nosocomial pneumonia, and survival at 60 days.
RESULTS: At admission, all patients had severe hypercapnic
respiratory failure (mean pH, 7.18+/-0.06; mean PaCO2,
94.2+/-24.2 mm Hg), sensory impairment, and similar clinical
characteristics. At 60 days, 22 of 25 patients (88%) who were
ventilated noninvasively were successfully weaned compared
with 17 of 25 patients (68%) who were ventilated invasively.
The mean duration of mechanical ventilation was 16.6+/-11.8
days for the invasive ventilation group and 10.2+/-6.8 days
for the noninvasive ventilation group (P = 0.021). Among
patients who received noninvasive ventilation, the probability
of survival and weaning during ventilation was higher (P =
0.002) and time in the intensive care unit was shorter
(15.1+/-5.4 days compared with 24.0+/-13.7 days for patients
who received invasive ventilation; P = 0.005). Survival rates
at 60 days differed (92% for patients who received noninvasive
ventilation and 72% for patients who received invasive
ventilation; P = 0.009). None of the patients weaned
noninvasively developed nosocomial pneumonia, whereas 7
patients weaned invasively did.
CONCLUSIONS: Noninvasive pressure support ventilation
during weaning reduces weaning time, shortens the time in the
intensive care unit, decreases the incidence of nosocomial
pneumonia, and improves 60-day survival rates.
The accuracy of substituted judgments in patients
with terminal diagnoses.
Sulmasy DP; Terry PB; Weisman CS; Miller DJ; Stallings RY;
Vettese MA; Haller KB
Georgetown University Medical Center, Washington, DC 20007,
USA.
sulmasyd@gunet.georgetown.edu
Ann Intern Med (United States) Apr 15 1998, 128 (8)
p621-9
BACKGROUND: Patients' loved ones often make end-of-life
treatment decisions, but the accuracy of their substituted
judgments and the factors associated with accuracy are poorly
understood.
OBJECTIVE: To assess the accuracy of judgments made by
surrogate decision makers; ascertain the beliefs, practices,
and clinical and sociodemographic factors associated with
accuracy of surrogates' decisions; assess the preferences of
patients for life-sustaining treatments; and compare
differences in accuracy across diagnoses.
DESIGN: Cross-sectional paired interviews.
SETTING: Outpatient practices of three university
hospitals.
PATIENTS: 250 patients with terminal diagnoses of
congestive heart failure, AIDS, amyotrophic lateral sclerosis,
lung cancer, and chronic obstructive pulmonary disease (50
patient-surrogate pairs in each group) and 50 general medical
patients and their surrogates.
MEASUREMENTS: The accuracy of surrogate predictions was
measured by using scales based on 10 potential treatments in
each of three hypothetical clinical scenarios.
RESULTS: Preferences varied according to mode of treatment
and scenario. On average, surrogates made correct predictions
in 66% of instances. Accuracy was better for the permanent
coma scenario than for the scenarios of severe dementia or
coma with a small chance of recovery (P < 0.001). In a
binary logit model, the accuracy of substituted judgments was
positively associated with the patient having spoken with the
surrogate about end-of-life issues (odds ratio [OR], 1.9 [95%
CI, 1.6 to 2.3]), the patient having private insurance (OR,
1.4 [CI, 1.1 to 1.7]), the surrogate's level of education (OR,
1.5 [CI, 1.2 to 1.9]), and the patient's level of education
(OR, 1.7 [CI, 1.4 to 2.2]). Accuracy was negatively associated
with the patient's belief that he or she would live longer
than 10 years (OR, 0.6 [CI, 0.5 to 0.7]), surrogate experience
with life-sustaining treatment (OR, 0.4 [CI, 0.3 to 0.5]),
surrogate participation in religious services (OR, 0.67 [CI,
0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [CI,
0.5 to 0.8]). Age, ethnicity, marital status, religion, and
advance directives were not associated with accuracy.
CONCLUSIONS: The accuracy of substituted judgments is
associated with multiple clinically apparent patient and
surrogate factors. This information can help clinicians
identify conditions under which substituted judgments are
likely to be accurate or inaccurate and can help target
populations for education designed to improve the accuracy of
surrogate decision making.
Vitamin D binding protein variants and the risk of
COPD.
Schellenberg D; Pare PD; Weir TD; Spinelli JJ; Walker BA;
Sandford AJ
Respiratory Health Network of Centres of Excellence,
University of British Columbia Pulmonary Research Laboratory,
St. Paul's Hospital, Vancouver, Canada.
Am J Respir Crit Care Med (United States) Mar 1998, 157 (3 Pt
1) p957-61
Although the development of chronic obstructive pulmonary
disease (COPD) in smokers shows genetic susceptibility, only
alpha1-antitrypsin deficiency has been identified as a
definite genetic risk factor. There have been three previous
studies in which associations between Gc-globulin phenotypes
and COPD have been investigated. Although some data suggest an
association, the were inconclusive. Because smoking is the
major risk factor for COPD, it may have been a confounding
factor in previous studies. We have investigated Gc-globulin
genotypic frequencies among 75 COPD patients and 64
nonobstructed controls. Both groups had significant smoking
histories: pack-years (mean +/- SD) of 52 +/- 30 and 48 +/-
27, respectively. The results show that homozygosity for the
Gc2 allele is protective against COPD (OR = 0.17, 95% CI =
0.03 to 0.83). There were no differences between genotypes for
lung elastic recoil values or for the level of upstream airway
resistance. Gc-globulin can enhance complement (C5a)-mediated
neutrophil chemotaxis. Because neutrophils play a role in
parenchymal destruction and airway inflammation, we examined
whether Gc-globulin's ability to enhance neutrophil chemotaxis
varied with genotype. We found no difference among genotypes
with respect to neutrophil chemotaxis suggesting that the
protective effect of the Gc2 allele is mediated through a
different mechanism.
[The importance of training intensity for improving
endurance capacity of patients with chronic obstructive
pulmonary disease]
Leuppi JD; Zenhausern R; Schwarz F; Frey WO; Villiger B
Thurgauer Schaffhauser Hohenklinik, Davos-Platz.
jorgl@med.usyd.edu.au
Dtsch Med Wochenschr (Germany) Feb 13 1998, 123 (7)
p174-8
BACKGROUND AND OBJECTIVE: Patients with COPD often have
exertional dyspnoea. They are incapacitated less by impairment
of pulmonary function than by deconditioning of the
cardiovascular and muscular systems. Pulmonary rehabilitation
through the currently customary "low intensity" training
programme can at best achieve limited improvement of aerobic
capacity. The aim of this study was to clarify whether in the
course of in-patient rehabilitation with a medical "high
intensity" training regimen patients with COPD can better
their endurance capacity (e.c.).
PATIENTS AND METHODS: Eleven patients with mild to moderate
COPD (ten men, one woman; average age 59 [54-76] years)
participated. In addition to optimal drug treatment they
undertook "high intensity" training (to 85-95% of maximally
achievable heart rate).
RESULTS: The patients achieved significant (P < 0.05)
improvement in maximal oxygen uptake, maximal performance and
walking distance in the 6-minute walking test.
CONCLUSION: Medically supervised "high intensity" training
can produce a significant rise in endurance capacity even in
patients with COPD.
Clinical, physiological and radiological features
of asthma with incomplete reversibility of airflow obstruction
compared with those of COPD
Boulet L.-P.; Turcotte H.; Hudon C.; Carrier G.; Maltais
F.
Dr. L.-P. Boulet, Hopital Laval, 2725 Chemin Sainte-Foy,
Sainte-Foy, Que. G1V 4G5 Canada
Canadian Respiratory Journal (Canada), 1998, 5/4
(270-277)
OBJECTIVES: To compare clinical features, pulmonary
function and high-resolution computed chest tomography (HRCT)
findings of asthmatic patients with a component of incomplete
reversibility of airflow obstruction (AIRAO) with those of
patients with smoking-induced chronic obstructive pulmonary
disease (COPD).
METHODS: Thirteen patients with COPD (six males and seven
females, mean age 59 years, mean smoking 50.5 pack-years) and
14 patients with AIRAO (six males and eight females, mean age
52 years) despite optimal treatment, with no significant
smoking history (mean 1.5 pack-years) and no significant
environmental exposure or any other respiratory disease, were
studied. Patients had respiratory questionnaires, pulmonary
function tests, allergy skin-prick tests and an HRCT to
evaluate possible parenchymal or bronchial abnormalities.
Eight patients in each group also had exercise tests. All
patients were stable at the time of the study.
RESULTS: As expected, atopy was more prevalent in AIRAO (n
= 13) than in COPD (n = 1) patients. Mean forced expiratory
volume in 1 s (FEV1) and forced vital capacity (percentage of
predicted value) were 39% and 61%, respectively, in COPD
patients and 49% and 71%, respectively, in AIRAO patients;
FEV1 improved by 18% in COPD patients and and by 22% in AIRAO
patients after use of inhaled salbutamol. Mean functional
residual capacity was greater in COPD patients than in AIRAO
patients (178% versus 144% of the predicted value), while the
mean carbon monoxide diffusing capacity of the lungs (DLCO)
was lower in COPD patients than in AIRAO patients (62% versus
89% of the predicted value). Exercise tolerance was similar in
both groups, as were postexercise changes in arterial oxygen
pressure (PaO2). Emphysematous changes were observed in COPD
patients and AIRAO patients who had evaluable HRCTs (10 versus
two patients, although very mild in asthma), bronchial
dilations (zero versus six patients), bronchial wall
thickening (two versus eight patients) and an acinar pattern
(one versus five patients). Mean thickness of the large airway
wall to outer diameter (intermediary bronchus) ratio was 0.176
in COPD and 0.183 in AIRAO (P > 0.05).
CONCLUSIONS: Asthma may lead to physiological features
similar to COPD but may be distinguished by demonstrating a
preserved DLCO and a higher ratio of airway to parenchymal
abnormalities on HRCT scan.
Alteration in nutritional status and diaphragm
muscle function
Dureuil B.; Matuszczak Y.
B. Dureuil, Departement d'anesthesie-reanimation, Hopital
Charles Nicolle, 1 rue de Germont, 76031 Rouen cedex
France
Reproduction Nutrition Development (France), 1998, 38/2
(175-180)
Diet-induced undernutrition causes deleterious changes in
the structure and function of the diaphragm muscle. Diseases
associated with somatic washing cause atrophy of the
respiratory muscles. In cachectic subjects, the diaphragm
muscle mass and thickness are reduced in proportion to the
reduction in body weight. In addition, respiratory muscle
strength and endurance are reduced more dramatically than the
weight loss. This finding suggests that malnutrition induces a
reduction in muscular mass which is associated with a decrease
in contractility. Diaphragmatic weakness may increase the risk
of respiratory failure in patients with chronic obstructive
pulmonary disease (COPD). The primary goal of a successful
nutritional programme is to improve the diaphragm strength by
correcting the mineral, electrolyte and energetic disturbances
at the muscular level, the latter being responsible for the
decreased contractability associated with malnutrition.
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