Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study.

OBJECTIVE: To determine whether a program incorporating smoking intervention and use of an inhaled bronchodilator can slow the rate of decline in forced expiratory volume in 1 second (FEV1) in smokers aged 35 to 60 years who have mild obstructive pulmonary disease. DESIGN: Randomized clinical trial. Participants randomized with equal probability to one of the following groups: (1) smoking intervention plus bronchodilator, (2) smoking intervention plus placebo, or (3) no intervention. SETTING: Ten clinical centers in the United States and Canada. PARTICIPANTS: A total of 5887 male and female smokers, aged 35 to 60 years, with spirometric signs of early chronic obstructive pulmonary disease. INTERVENTIONS: Smoking intervention: intensive 12-session smoking cessation program combining behavior modification and use of nicotine gum, with continuing 5-year maintenance program to minimize relapse. Bronchodilator: ipratropium bromide prescribed three times daily (two puffs per time) from a metered-dose inhaler. MAIN OUTCOME MEASURES: Rate of change and cumulative change in FEV1 over a 5-year period. RESULTS: Participants in the two smoking intervention groups showed significantly smaller declines in FEV1 than did those in the control group. Most of this difference occurred during the first year following entry into the study and was attributable to smoking cessation, with those who achieved sustained smoking cessation experiencing the largest benefit. The small noncumulative benefit associated with use of the active bronchodilator vanished after the bronchodilator was discontinued at the end of the study. CONCLUSIONS: An aggressive smoking intervention program significantly reduces the age-related decline in FEV1 in middle-aged smokers with mild airways obstruction. Use of an inhaled anticholinergic bronchodilator results in a relatively small improvement in FEV1 that appears to be reversed after the drug is discontinued. Use of the bronchodilator did not influence the long-term decline of FEV1.

Recovery of alertness after CPAP in apnea.

Excessive daytime sleepiness is the most common symptom in OSAS. Administering CPAP improves breathing during sleep. We evaluated the time course of the recovery of alertness following CPAP therapy in OSAS patients. Thirty-nine patients with OSAS were treated with CPAP and evaluated after one, 14, or 42 nights of treatment, 13 patients being randomly assigned to each group. All received a diagnostic polysomnogram and MSLT before treatment. The three groups had similar baseline values for nocturnal respiratory disturbance, oxygenation during sleep, fragmentation of sleep, and level of EDS. CPAP treatment was associated with a significant improvement in sleep-related respiration, oxygenation, and sleep fragmentation. The EDS showed significant improvement after one night, and further significant improvement after 14 nights, but no further significant improvement after 42 nights. The differential rate of improvement in nocturnal parameters compared with that of primary complaint of EDS suggests that OSAS patients experience a chronic functional sleep loss. As with sleep deprivation, recovery of alertness in OSAS requires several nights of normal sleep.

Frequency and significance of cardiac arrhythmias in chronic obstructive lung disease.

Ambulatory electrocardiograms obtained in 69 patients enrolled in the nocturnal oxygen therapy trial group were examined for frequency and significance of arrhythmias in patients with stable chronic obstructive lung disease. Ventricular premature beats occurred in 83 percent, ventricular bigeminy in 68 percent, paired ventricular premature beats in 61 percent, and nonsustained ventricular tachycardia in 22 percent of the patients. Supraventricular tachycardia occurred in 69 percent. Repetitive ventricular arrhythmia occurred in 64 percent of the patients, and was significantly more frequent in men and in patients with edema or elevated PCO2. Ventricular premature beats greater or equal to 25 per hour occurred in 35 percent of the patients. Univariate and multivariate Cox proportional hazards analysis showed that a history of coronary heart disease, increased sinus heart rate and decreased maximum work load (measured by maximal treadmill exercise test)--but not arrhythmias--were predictors of death.

Evaluation of the effectiveness of uvulopalatopharyngoplasty.

A new surgical procedure to treat obstructive sleep apnea by uvulopalatopharyngoplasty (UPPP) was evaluated in 66 patients, 63 men and 3 women, with objectively documented sleep apnea syndrome. Removal of redundant tissue in the oropharynx (UPPP) significantly improved excessive daytime sleepiness, reduced by half the frequency of apneas and hypoxia occurring during sleep, and improved the quality of sleep. Closer analysis indicated that all 66 patients did not benefit to the same degree. Among patients classified as responders, the frequency of apnea was reduced to a level seen in healthy adults of the same age, measures of sleep approached normal, and excessive daytime sleepiness was eliminated. In nonresponders, frequency of apnea and consequent disruption of sleep was not reduced, but nocturnal hypoxia was improved.

Early extubation after coronary artery bypass: brief report.

We performed a prospective study of early post-coronary artery bypass graft (CABG) ventilator management and weaning. Sixty-three patients were studied consecutively; 27 were managed by the standard post-CABG weaning practice at this institution, and 36 were managed by respiratory therapists using a protocol with specific ventilation and weaning guidelines. The mean time to extubation was decreased by 41% using the protocol. Arterial blood gas sampling was reduced 42%. There were no deaths in either group. Physicians were alerted to problems necessitating interruption of the protocol in six of 36 patients studied. This protocol proved easy to follow and safe in the hands of respiratory therapists. It lowered costs and improved patient comfort.

Night-to-night consistency of apneas during sleep.

The consistency of apneas from night to night was examined in 2 groups of patients. The first group had more than 100 apneas per night (frequent apnea) and the second group had less than 100 apneas per night (infrequent apnea). All patients underwent clinical polysomnography for 2 nights, with no significant weight change or treatment occurring between recordings. The frequent apnea group showed a consistent number of apneas on the 2 nights (r = 0.92, p less than 0.01), whereas the infrequent apnea group showed a highly variable number of apneas (r = 0.35, p greater than 0.10). The correlations on apnea index (apneas per hours of sleep) showed a similar result. Apnea duration and type were consistent in both groups of patients.

The potential role of respiratory therapy equipment in cross infection. A study using a canine model for pneumonia.

Experimental Pseudomonas aeruginosa pneumonia was induced in 8 dogs that had radiation-induced leukopenia. Three dogs were supported by mechanical ventilation (MV), 3 received continuous heated aerosol therapy (CHAT), and 2 did not receive respiratory therapy and served as control animals. The animals were studied in a carefully controlled environment until they succumbed to infection or they were killed at 24 h. An air sampler was used to collect exhaled P. aeruginosa aerosols at distances as far as 15 feet from the dogs at multiple time intervals. Water condensate in the tubing of MV and CHAT equipment was collected and cultured at the same intervals. Results showed that all dogs had multilobar P. aeruginosa pneumonia at necropsy. Control dogs did not exhale aerosols containing P. aeruginosa. Animals that were supported by MV, exhaled contaminated aerosols, but organisms could not be recovered at distances greater than 2 feet. In contrast, aerosols containing P. aeruginosa were recovered at distances as far as 15 feet from the animals receiving CHAT. Furthermore, as much as 1L of water condensate was collected in a 24-h period from tubing associated with MV and CHAT. Although the nebulizers and humidifiers remained sterile, tubing condensate was contaminated with as much as 10(7) colony-forming units per ml of P. aeruginosa in 5 of the 6 animals receiving either MV or CHAT. Contamination of tubing by P. aeruginosa was present as early as 8 to 12 h. This study identifies potential sources for cross infection through an airborne route for CHAT or from direct contact with contaminated tubing.

Protriptyline in the treatment of sleep apnoea.

Nine patients with obstructive sleep apnoea were treated with 5 to 20 mg of protriptyline each night for two to 18 months. In four patients, there was dramatic, sustained improvement in symptoms and measured sleep quality and apnoea frequency and duration. There was no improvement in two patients and three developed intolerable side-effects preventing adequate treatment. Apnoea frequency was the only apparent predictor of responsiveness. Those with fewer than 30 episodes of apnoea per hour consistently improved. Only two of four patients with more than 60 episodes per hour improved. These results provide additional evidence that a carefully monitored trial of protriptyline may benefit selected patients with mild to moderate obstructive sleep apnoea.

Adverse effects of tracheostomy for sleep apnea.

Tracheostomy resulted in dramatic and sustained improvement in the symptoms of 11 patients with upper airway sleep apnea. However, seven of eight patients who had a standard tracheostomy experienced tracheal granuloma or stomal stenosis. Tracheostomy was revised in five of these eight patients using cervical skin flaps. Three of the 11 patients had a skin flap tracheostomy as the original procedure. Only two of eight patients had tracheal complications after a skin flap procedure. Postoperative problems unrelated to the procedure included recurrent purulent bronchitis in four and psychosocial difficulties in ten. Permanent tracheostomy should be limited to patients with serious cardiopulmonary complications of upper airway sleep apnea. The cervical skin flap is the preferred procedure for long-term tracheostomy in these patients.

Differential lung ventilation with a modified ventilator.

To achieve synchronized differential pulmonary ventilation, an Ohio 560 ventilator was modified through separation of the outputs of the deep breath bellows and the tidal volume bellows and providing independent volume, flow rate, PEEP, oxygen-humidification, and alarm systems. The described ventilator modification is simple, inexpensive, and does not alter the performance characteristics of the original unmodified ventilator. Differential lung ventilation may be more easily achieved with this modified ventilator than with the simultaneous use of two ventilators or external electronic synchronizers.

The significance of superior vena cava syndrome developing in a patient with sarcoidosis.

The development of superior vena cava syndrome in sarcoidosis is uncommon, as is the development of lymph node enlargement after the pulmonary component of the disease is well established. A search for other etiologic factors is indicated.

Diagnostic accuracy in peripheral lung lesions. Factors predicting success with flexible fiberoptic bronchoscopy.

Ninety-seven consecutive peripheral lung lesions were evaluated by biplane fluoroscopically guided flexible fiberoptic bronchoscopy and analyzed to define features that predict diagnostic yield. The overall diagnostic accuracy was 56 percent (63 percent for malignant and 38 percent for benign lesions). The most important characteristic associated with a positive cyto- or histopathologic diagnosis was size of the lesion; the yield was 28 percent when the diameter was less than 2.0 cm compared to 64 percent if the diameter was greater than or equal to 2.0 cm (P = 0.0035). The diagnostic yield was similar for lesions located in the outer and middle third of the lung if the diameter was greater than 2.0 cm; inner one-third lesions were correctly diagnosed more frequently, related in part to the larger size of these lesions. There was no significant difference in diagnostic yield for the following: segmental location, greatest distance from carcina on either the posteroanterior or lateral radiograph, or radiographic characteristics of the lesion. We conclude that biplane fluoroscopically guided flexible fiberoptic bronchoscopy is a reasonable diagnostic procedure for peripheral lesions greater than or equal to 2.0 cm in diameter, but that alternative procedures should be used for lesions under 2.0 cm in diameter.

Hypersomnolence and intermittent upper airway obstruction. Occurrence caused by micrognathia.

A patient with hypersomnolence, micrognathia, and respiratory insufficiency had been treated eight years for narcolepsy. Sleep apnea because of upper airway obstruction was found, and a tracheostomy was performed. Following this the hypersomnolence and respiratory insufficiency resolved. This case emphasizes the importance of carefully evaluating the condition of patients complaining of hypersomnolence to detect those with intermittent upper airway obstruction occurring during sleep.