Breathing retraining: effect on anxiety and depression scores in behavioural breathlessness.

Thirty-six patients underwent assessment of behavioural breathlessness which included monitoring of breathing patterns and end tidal CO2 concentration and completion of questionnaires relating to hyperventilation (HV), anxiety and depression. Twenty-two patients had a positive assessment and underwent breathing retraining. Assessments were repeated immediately after re-training and 2 months later. Ten of the patients (Group A) had behavioural breathlessness either as the primary problem or secondary to an established clinical condition, and twelve (Group B) in association with chronic fatigue. Before re-training, resting end-tidal PCO2 was significantly lower in Group A than Group B (p < 0.05), but there was no significant difference in mean scores for HV-related symptoms, anxiety or depression. Following breathing retraining, both groups showed improvements in breathing patterns, end tidal CO2 levels and scores for HV-related symptoms which were sustained. In Group A the mean score for anxiety decreased (p < 0.01) and the score for depression was significantly lower than in Group B (p < 0.05). Although mean scores for anxiety and depression in Group B did not change significantly, some individuals in the group did show sustained improvement. There was no improvement in symptoms associated with chronic fatigue in Group B. In behavioural breathlessness, breathing retraining is of benefit, not only in restoring more normal patterns of breathing but also in reducing anxiety, particularly in patients without the complication of chronic fatigue.

The use of a new breath-actuated inhaler by patients with severe airflow obstruction.

The ability of patients with severe airflow limitation (forced expiratory volume in one second less than 1.0 l or peak expiratory flow rate less than 200 l.min.1) to use a new breath-actuated inhaler (BAI) was assessed. One hundred and fifty six patients attending two respiratory units entered and completed the study. Subjects were instructed how to use the device and after attempting to trigger the BAI had flow-volume loops measured. One hundred and fifty one (97%) were able to actuate the inhaler on their first (146) or second (5) attempt. The five unsuccessful patients did not have the most severe airways obstruction. It is concluded that this new device, which is actuated at low inspiratory flow rates, can be used by patients with severe airflow limitation and represents an important advance in inhaler technology.

Coughing can relieve or exacerbate symptoms in asthmatic patients.

From about 1190 to the present day opposing views have been expressed about the effects of coughing in patients with asthma. Some accounts have stated that it brought relief and others that it exacerbated asthma, whereas others thought that it could have both effects. In the present investigation, 187 patients with a clinical diagnosis of asthma were asked whether coughing relieved or exacerbated their asthma. In 41.7% coughing caused exacerbation, in 29.9% it brought relief, in 9.9% it had no effect, and in the remaining 18.7% it sometimes exacerbated their symptoms and sometimes brought relief. When asthma was exacerbated, the most common symptom induced was breathlessness, and then wheezing; chest tightness was the least frequent. When coughing brought relief it was mainly through the expectoration of sputum. However, a small proportion of patients found relief even if there was no expectoration. If coughing exacerbates asthma and persists in the face of treatment with standard medication, then treatment specifically directed at its diminution could reduce morbity considerably.

Evaluation of the need for follow-up in an out-patient clinic.

We have identified 164 patients regularly attending a chest clinic whose condition had been defined as stable on the basis of clear-cut criteria. These patients were randomly allocated to either routine follow-up at 3 monthly intervals (the 'follow-up' group) or annual follow-up (the 'discharge' group). After 1 year, on the basis of a questionnaire sent to the patients' general practitioners, there were no significant differences in outcome between the two groups apart from a just-significant increase in deaths in the 'follow-up' group. Nevertheless, at the conclusion of the trial clinic doctors felt that only 45% of patients and general practitioners that only 27% of patients should be discharged from the clinic. At the conclusion of the study patients in the 'discharge' group were significantly more likely to feel that they had been attending too infrequently and that their condition had worsened, although the latter was not borne out by objective data. We suggest that all these patients could have been discharged from the clinic without any difference in outcome. This study highlights the reluctance of clinic doctors and general practitioners to consider and effect the discharge of stable patients from routine clinic attendance.

Respiratory impairment in inflammatory bowel disease: does it vary with disease activity?

Serial assessments of respiratory function were made in 44 patients with inflammatory bowel disease. Pulmonary function tests were performed at the initial assessment and after three months to see if abnormality was associated with alteration in disease activity, drug therapy or with evidence of immunological disturbance. Fourteen patients (32%) had some abnormality of respiratory function when first investigated. Seven (16%) had a reduced gas transfer factor but these abnormalities were not related to disease activity, drug therapy or any immunological variable. Elevation of both functional residual capacity and residual volume was found in nine (20%) patients at the initial assessment. These abnormalities appeared to be associated with active inflammatory bowel disease and in four of these patients lung volumes returned to normal at 3 months when the bowel disease was in remission.

Do chest physicians follow-up too many patients?

We have examined the pattern of attendance of 750 randomly selected regular attenders at a chest outpatient clinic and sought the patients' views on the frequency of their follow-up appointments and the possible consequences of discharge to the care of the general practitioners. In addition, the clinic doctors and the patients' general practitioners were asked about the appropriateness of the frequency of follow-up and whether the pattern of attendance should change or the patient be discharged. Patients were most commonly seen at three monthly intervals. Clinic doctors felt that 24% and general practitioners that 9% of patients attended too often while only 2% of patients felt that this was the case. Clinic doctors recommended discharge for 28% and general practitioners for 21% of patients. Sixty-nine per cent of patients felt that their condition would be unchanged or would improve if they were discharged to the care of their general practitioners. Our findings suggest that at least 20% of our patients should be discharged to the care of their general practitioners, and, if the patients are correct in their interpretation of the consequences of discharge, that as many as 70% could safely be discharged.

Legionella pneumonia complicating Wegener's granulomatosis.

We describe a previously healthy man who presented with features consistent with Wegener's granulomatosis. While undergoing investigation, he developed acute respiratory failure, thought to represent progression of his vasculitis. Open lung and sinus biopsies were performed to obtain the diagnosis. Vasculitis was confirmed on the paranasasl biopsy, and the lung biopsy showed pneumonia due to Legionella pneumophila, an association not previously reported in Wegener's granulomatosis. If immunosuppressive therapy had been started without making the diagnosis of Legionella pneumonia on lung biopsy, the patient might well have succumbed to the infection.

Are reduced lung volumes in IDDM due to defect in connective tissue?

Lung volumes were measured by spirometry and helium-dilution technique in 28 young adult men with insulin-dependent diabetes mellitus (IDDM) of long duration and compared with 16 age- and height-matched adult men without diabetes. Reduced values for forced expiratory volume at 1 s, vital capacity, functional residual capacity, total lung capacity, residual volume, and single-breath carbon monoxide transfer factor were found for the IDDM patients compared to the control subjects. The results are consistent with reduced lung volumes in IDDM patients and did not correlate with the presence or absence of mild cheiroarthropathy but may relate to duration of diabetes.

A standardised comment scheme for routine pulmonary function test results.

Observed values of ventilatory capacity, gas transfer and lung volumes in 840 patients were used to formulate a standardised scheme of descriptive comments. Response to bronchodilators was also defined. Absolute differences between measured and predicted values are used to identify normal and abnormal patterns of results, together with an overall pattern. The algorithms are suitable for computer use. The scheme has been in routine manual use for four years and can be used by any laboratory in which the necessary quality control standards are applied.

Short term variability in FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defects.

Short term variability in FEV1 and responsiveness to inhaled bronchodilator were measured in 150 patients with obstructive ventilatory defects. The range of initial FEV1 was 0.5-4.71 and the natural variability over a 20 minute period when expressed in absolute terms was similar over the entire range, and differed insignificantly from that found in normal subjects. The increase in FEV1 and vital capacity (VC) required to exclude natural variability with 95% confidence in these patients was 160 ml and 330 ml respectively. Natural variability when expressed in percentage terms was negatively correlated with the level of FEV1 recorded. The analysis of changes in FEV1 and VC after administration of bronchodilator used absolute and percentage criteria for response. The number of responders differed considerably according to the criterion used. In those defined by the absolute criterion as responders there was no evidence that size of response was related to level of FEV1. Percentage criteria have traditionally been used to identify responses to bronchodilator that may be clinically useful, while absolute criteria, although statistically valid, have not been favoured. Reappraisal of the criteria used and their limitations and implications is required.

Short term variability in FEV1: relation to pretest activity, level of FEV1, and smoking habits.

The natural variability in forced expiratory volume in one second (FEV1) over 20 minutes was determined in 54 fit hospital employees and 13 patients with restrictive lung disorders. Initial FEV1 ranged from 1.1 to 6.3 1 BTPS. Variability when expressed as absolute change was similar at all levels of FEV1, so that, when expressed as percentage change, variability decreased with increasing FEV1. Smoking habits did not appear to affect variability but activity before the test did. On the basis of these results an absolute change in FEV1 of 190 ml would be necessary for 95% confidence that the change in FEV1 occurred other than by chance in any one individual. This suggests that the absolute change in FEV1 might be a more reliable criterion than percentage change when distinguishing between natural variability and a response to inhalation of bronchodilators.

Psychological factors contributing to disproportionate disability in chronic bronchitis.

Disability in fifty chronic bronchitis patients was measured by the twelve-minute walking test. The degree of disability was examined in relation to lung function and a measure of disproportion of disability was derived. This measure was significantly related to a number of attitude measures, in particular the patients' beliefs about treatment and treatment outcome, but was not strongly related to psychiatric disturbance on the GHQ. However, high levels of psychiatric disturbance were found within the overall sample.

Effect of attitudes and beliefs on exercise tolerance in chronic bronchitis.

In 50 patients with chronic bronchitis the relation was assessed between exercise tolerance and pulmonary function and psychological factors, including subjective perception of exertion, mood, general psychiatric disturbance, and the attitudes and beliefs held by patients concerning themselves, their illness, and its treatment. Ventilatory capacity was significantly correlated with but a poor predictor of exercise tolerance. Subjective perception of exertion was most closely correlated with exercise tolerance. The distance walked in a 12-minute exercise test was significantly correlated with measurements of mood and with several attitudes and beliefs. Attitudes and beliefs greatly outweighed measurements of mood and ventilatory capacity as components in a multiple regression predicting distance walked in 12 minutes. This method of psychological assessment emphasises the importance of attitudes and beliefs in respiratory disability and may have useful applications in rehabilitation in other chronic diseases.

Quality control in pulmonary function testing. A help or a hindrance?

The results of 120 sets of ventilatory capacity, lung volume (LV) and carbon monoxide transfer factor (TCOSB) measurements, 40 sets from each of three pulmonary function laboratories in one city, were examined retrospectively. Vital capacity (VC) was estimated by a forced expiratory manoeuvre (FVC), a relaxed expiratory manoeuvre (VCR) and an inspiratory manoeuvre (VCI) in the three different tests. Differences between VCR and FVC ranged from--88 ml to + 1 400 ml with a mean of + 47 ml. VCI differed from the largest estimate of expiratory VC by--1 800 ml to + 300 ml with a mean of--480 ml. Such differences, which were observed in all three laboratories, affect the calculations in each test and thus the final results quoted. Adequate quality control therefore requires comparison of estimates of VC not only within a test but also between tests. Although more time must be spent with some patients, technical errors and poor patient performance can be distinguished from true changes in pulmonary function, thus better enabling the clinician to assess the relationship between the results and the clinical condition of the patient.

Effect of oral salbutamol and slow-release aminophylline on exercise tolerance in chronic bronchitis.

In a double-blind placebo-controlled trial in 24 patients fulfilling the MRC criteria for chronic bronchitis, oral salbutamol 4 mg and slow-release aminophylline (Phyllocontin) 450 mg produced similar and significant (p less than 0.05) mean increases in forced expiratory volume in one second (FEV1). A significantly greater increase in mean FEV1 and forced vital capacity (FVC) was seen when both drugs were given although there was no statistical evidence of synergistic interaction. Salbutamol significantly increased the mean distance walked in 12 minutes (12MD) (p less than 0.02) by 56 metres and a similar increase of 54 metres (p less than 0.001) was seen after Phyllocontin. With both drugs in combination mean 12MD increased by 51 metres (p less than 0.02 cf placebo), a change not significantly different from that observed with either drug alone. Oral salbutamol and Phyllocontin improve exercise tolerance in chronic bronchitis. The significantly greater changes in FEV1 and FVC resulting from simultaneous administration of the two drugs are not associated with further improvement in exercise tolerance.