Pheasant rearer's lung.

A 47-year-old gamekeeper presented with an 8 month history of variable breathlessness, cough and clinical features of severe interstitial lung disease. Open lung biopsy showed an extrinsic allergic alveolitis, which we believe related to his work rearing pheasants. Initially he was resistant, despite advice, to changing his occupation but subsequently, although ceasing exposure to pheasants and beginning treatment with corticosteroids, his disease progressed to the point where he developed respiratory failure and was referred for lung transplantation. Sadly, he died of progressive respiratory failure and cor pulmonale complicated by bronchopneumonia before this could be achieved.

The clinical course and management of thoracic empyema.

We report a prospective multi-centre study of the clinical course and hospital management of thoracic empyema in 119 patients (mean age 54.8). The commonest presenting symptom was malaise (75%), 55% were febrile; 31% were previously well with no predisposing condition. Initial treatments were antibiotics alone (5), needle aspirations (46), intercostal tube drainage (61), rib resection (3) and decortication (4). Overall, intercostal drainage was used in 77 patients (16 failed aspirations), surgical rib resection in 24 (1 failed aspirations, 20 failed drainage), and surgical decortication in 28 (6 failed aspirations, 17 failed drainage). Only 4 patients received intrapleural fibrinolytic agents. Aspiration and drainage were likely to fail if the empyema was > 40% of the hemithorax. Median time from treatment start to discharge was: aspirations, 26 days; drainage, 23 days; resection 11 days; decortication, 12 days. Overall 21 patients died (12 with empyema as the major cause); two had been surgically treated. Mortality correlated with age, diabetes, heart failure, and low serum albumin at admission. Infecting organisms, identified in 109 patients (92%) included anaerobes (37), Str. melleri (36), and Str. pneumoniae (28). Six months after discharge, all but six survivors had regained their previous health.

Symptomatic benefit of supplemental oxygen in hypoxemic patients with chronic lung disease.

We have compared the symptomatic benefit of air and oxygen at rest in hypoxemic patients with chronic obstructive airway disease (COAD) or interstitial lung disease (ILD). A total of 12 severely disabled patients with COAD (mean +/- SEM, PaO2, 50.3 +/- 3.7 mm Hg) and 10 with ILD (PaO2, 48.0 +/- 3.1 mm Hg) received 28% oxygen and air by Venturi face mask, each gas on two occasions, in a double-blind randomized fashion. SaO2 increased (p less than 0.01) in both groups during oxygen breathing: COAD, 85.1 +/- 2.3% versus 93.1 +/- 1.4%; ILD, 85.5 +/- 1.7% versus 94.7 +/- 0.9%. The patients with COAD stated that air helped their breathing on 15 of 24 occasions and that oxygen helped on 22 of 24 occasions (p less than 0.05). In the patients with ILD the values were 6 of 20 and 13 of 20 occasions, respectively (p less than 0.05). In both groups of patients the severity of breathlessness recorded on a 100-mm visual analog scale was significantly (p less than 0.05) lower during oxygen breathing: COAD, 29.6 +/- 4.5 versus 45.6 +/- 6.0; ILD, 30.2 +/- 5.1 versus 48.1 +/- 4.4. Ventilation measured by magnetometers was significantly lower during oxygen breathing in the patients with COAD (8.2 +/- 1.0 versus 9.3 +/- 1.1 L/min; p less than 0.05), but the difference between oxygen and air in patients with ILD was not statistically significant (9.3 +/- 1.3 versus 11.2 +/- 1.6 L/min; p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective randomized comparison of fine needle aspiration biopsy and fibreoptic bronchoscopy in the investigation of peripheral pulmonary opacities.

Twenty-nine patients, aged 66(+/- 7) years with a peripheral pulmonary opacity (mean diameter 3.6 +/- 1.8 cm) believed to be a tumor, were randomly allocated to initial investigation by either fibreoptic bronchoscopy or percutaneous fine needle aspiration biopsy, the latter performed under fluoroscopic control. The patients proceeded to the alternative investigation in the event of the first failing to achieve a diagnosis. Malignancy was confirmed by the initial procedure in 14/15 patients randomized to fine needle aspiration biopsy but only in 1/14 patients randomized to fibreoptic bronchoscopy (P less than 0.01). Overall, these figures were 25/28 fine needle aspiration biopsy and 2/15 fibreoptic bronchoscopy (P less than 0.01). These results confirm the clinical suspicion that fine needle aspiration biopsy is far more likely than fibreoptic bronchoscopy to establish the presence of malignancy in peripheral pulmonary opacities.

Ventilation perfusion lung scans in the management of suspected pulmonary embolism.

The purpose of the study was twofold: (a) to relate the degree of clinical suspicion of pulmonary embolism (PE) to the findings of isotope ventilation-perfusion (V/Q) scans, and (b) to determine the extent to which the scan results influence patient management. A questionnaire was completed by the requesting clinician before V/Q scanning in 60 consecutive in-patients in whom PE had, with varying degrees of probability, been considered possible. Retrospectively, the case notes were reviewed to determine whether or not the patients were anticoagulated when discharged. Prior to scanning, PE was considered probable or almost certain in 35 (58 per cent) patients and unlikely or very unlikely in 25 (42 per cent) patients. Thirty-seven (62 per cent) scans were confidently reported positive or negative for PE; in the remaining 23 (38 per cent) cases, the scan report was necessarily inconclusive. The clinical assessment was supported by the scan result in 23/25 (92 per cent) patients in whom PE was felt unlikely or very unlikely, but in only 14/35 (40 per cent) in whom this diagnosis was felt probable or almost certain. Twenty (33 per cent) patients were already anticoagulated when scanned; this treatment was initiated in nine (15 per cent) and discontinued in eight (13 per cent) in the light of the scan result. Isotope V/Q scans are not always useful in confidently confirming or excluding the presence of PE. Nevertheless, the scan reports, even when necessarily guarded and somewhat at variance with the clinical assessment of the probability of PE, strongly influence clinicians in their decisions as to whether to anticoagulate their patients.

Adverse effect of additional weight on exercise against gravity in patients with chronic obstructive airways disease.

The effects of an acute, artificially simulated increase in body weight on exercise performance were examined in 14 patients of normal weight (mean (SD) body mass index 22.3 (2.7)), age 61 (8) years) with chronic obstructive airways disease (FEV1 1.2 (0.5) 1; vital capacity (VC) 2.9 (0.6) 1), and in six normal subjects with similar age and sex distribution. The patients performed a six minute walking test and a symptom limited step climbing test both with and without an additional 10 kg weight (two leaded aprons). The normal subjects performed a step test with and without the additional weight. Ventilation (VE) and oxygen consumption (VO2) were measured during step climbing. Resting spirometric values were not altered by the additional weight. In the patients the median number of steps climbed fell from 67.5 when they were unweighted to 44.5 when they were weighted. Mean VE and VO2 were increased during weighted step climbing by 14% and 13% but the maximum levels of VE and VO2 achieved were similar during unweighted and weighted exercise (VE 36.8 (8.6) and 37.3 (10.2) 1 min-1, VO2 1.35 (0.3) and 1.41 (0.4) 1 min-1 respectively). The normal subjects were readily able to complete 150 steps both with and without the additional weight. In the patients the six minute walking distance fell only slightly with the extra weight, from 554 (SD 61) to 540 (62) m. A subsidiary study was carried out in six healthy younger subjects in which VE and VO2 were measured during a 5.6 km/h six minute treadmill walk at zero incline. The additional weight did not alter VE or VO2 during exercise. In conclusion, a small acute increase in body weight substantially worsened the already reduced "uphill" exercise performance in patients with chronic obstructive airways disease because of its effect on ventilation and oxygen consumption. These results suggest that modest weight loss might benefit patients with chronic obstructive airways disease even though they may be only slightly above their ideal body weight.

Effects of an external resistance on maximum flow in chronic obstructive lung disease: implications for recognition of coincident upper airway obstruction.

To determine how the presence of generalised airflow limitation due to chronic obstructive lung disease affects the recognition of simulated upper airway obstruction, a study was carried out in 12 patients (mean (SD) age 57 (7) years) with chronic obstructive lung disease (FEV1% predicted 53 (22), range 21-70) and 12 matched control subjects. Patients and control subjects performed maximal inspiratory and expiratory flow-volume curves in a variable volume plethysmograph with and without upper airway obstruction simulated at the mouth with a series of polythene washers of internal diameter 4, 6, 8, 10, and 12 mm. In patients, as in normal subjects, peak expiratory flow (PEF) and maximum inspiratory flow at 50% of vital capacity (Vmax50) were more sensitive to upper airway obstruction than were FEV1 or maximum expiratory flow at 50% VC (VEmax50); but the reductions in all indices caused by simulated upper airway obstruction were smaller in the patients than in the controls. The fall in PEF (whether expressed in absolute units or as a percentages) consequent on severe (4 mm) upper airway obstruction became smaller with increasing severity of chronic obstructive lung disease. The subjects also produced flow-volume curves with and without 6 mm upper airway obstruction while breathing helium and oxygen (heliox). In both groups the effects of heliox on PEF and Vmax50 were increased when upper airway obstruction was simulated. It was confirmed that the functional recognition of upper airway obstruction is more difficult in patients with chronic obstructive lung disease than in normal subjects and this difficulty increases with severity of disease; an unusually large increase in PEF or Vmax50 while the patient is breathing heliox should raise the suspicion of coexisting upper airway obstruction, but such a pattern is not specific.

Opportunist pulmonary infection with Legionella bozemanii.

Three cases of pulmonary Legionella bozemanii infection in immunocompromised patients are described. The diagnosis was made by culture in each case and would not otherwise have been made, and it is recommended that a culture specific for Legionella species should be included in the investigation of patients with suspected opportunist pulmonary infections.

Evidence of prednisolone induced mood change ('steroid euphoria') in patients with chronic obstructive airways disease.

1. It is a clinical impression that some patients given oral corticosteroids develop a sense of wellbeing that is 'inappropriate' to improvements in physical health. This has been termed steroid 'euphoria', but unlike steroid-induced psychosis it has not been documented. 2. To test for the size and frequency of this phenomenon, 20 patients with severe chronic obstructive airways disease (mean FEV1 0.86 l) were given 30 mg of prednisolone for 14 days, after a period of placebo administration in a single-blind study. 3. Lung spirometry and arterial saturation during exercise were measured serially, together with established measures of mood state. 4. No changes in spirometry or arterial saturation during exercise were detected until 7 days of active therapy. 5. Mood state did not change during the placebo period, but small significant reductions in anxiety and depression were measured after 3 days of prednisolone and before any measurable improvement in lung function. Mood state did not then further improve, despite measurable improvements in lung spirometry. 6. This is evidence that prednisolone may produce a mild 'inappropriate' sense of wellbeing within a population receiving the drug, rather than as an occasional idiosyncratic response.

Bronchiolitis obliterans organising pneumonia in a patient with ulcerative colitis.

A young woman with ulcerative colitis developed pneumonia, which responded to corticosteroids. Histological examination showed this to be bronchiolitis obliterans organising pneumonia.

Clinical and bronchoscopic diagnosis of suspected pneumonia related to AIDS.

In a series of 25 patients with suspected pneumonia related to the acquired immune deficiency syndrome (AIDS) the first 12 underwent routine fibreoptic bronchoscopy and bronchoalveolar lavage with or without transbronchial biopsy before treatment. Eight were found to have Pneumocystis carinii pneumonia and had typical clinical presentations with a prolonged history of symptoms, including a dry cough, and bilateral diffuse alveolar or interstitial shadowing in chest radiographs. Among the subsequent 13 cases, 11 had similar clinical presentations and were treated with high doses of intravenous co-trimoxazole without bronchoscopy first. Bronchoscopy was performed in those who deteriorated at any stage or failed to improve by the fifth day of treatment. Nine patients recovered and were discharged. In two patients who died P carinii pneumonia was confirmed in one but no diagnosis was made in the other. The early and late survival in both groups of patients was similar. In patients at high risk for AIDS who have clinical features suggestive of P carinii pneumonia starting treatment with intravenous co-trimoxazole is justified. The few patients who deteriorate or fail to respond should undergo bronchoscopy with bronchoalveolar lavage and transbronchial biopsy.

Left recurrent laryngeal nerve palsy as the presenting feature of sarcoidosis.

We report a case of sarcoidosis in which the presenting features were hoarseness of voice, hilar lymphadenopathy and paralysis of the left recurrent laryngeal nerve. Sarcoidosis does not usually enter into the differential diagnosis in this situation, which almost invariably implies the presence of malignant disease, particularly either lymphoma or bronchial carcinoma.

Radiographic features in patients with pulmonary manifestations of the acquired immune deficiency syndrome.

The radiographic findings in 14 episodes of pulmonary pathology, occurring in 13 patients with the acquired immune deficiency syndrome (AIDS) are described. The patients presented over a 15-month period. All were homosexual men with serum antibodies to human T-cell lymphotrophic virus III. Pneumocystis carinii pneumonia was the most common manifestation, occurring in seven of the 14 episodes. Radiographic appearances in five of these were classical, with bilateral perihilar ground-glass shadowing initially. In one the appearances were complicated by a superadded bacterial infection and in one the chest radiograph was normal. Bacterial infections occurred in five of the 14 episodes and, when present, showed the characteristic radiographic appearances of the causative organism. Three patients had widespread Kaposi's sarcoma. Bronchoscopy, broncho-alveolar lavage and transbronchial biopsy were often necessary to identify the causative agent. They were also indicated when atypical radiographic appearances occurred during the course of treatment as additional organisms could be found. The radiographic appearances of the conditions reported are felt to be sufficiently characteristic for the radiologist to play a useful role in suggesting the diagnosis and in monitoring the progression of disease in these patients.

Performance, ventilation, and oxygen consumption in three different types of exercise test in patients with chronic obstructive lung disease.

Seventeen patients (six men and 11 women, mean age 66 years) with severe chronic obstructive lung disease (mean FEV1 0.8 (SD 0.3)1) performed three different types of exercise test on four occasions within one week. Three daily doses of placebo tablets were given between the third and fourth attempt at each test. The tests were the 12 minute walking test, a fixed rate and height paced step test, and a cycle ergometer test in which the work rate was increased by 10 watts each minute. Performance increased significantly (p less than 0.01) between the first and fourth attempts in each type of test (12 min walking distance 16% (SD 20%); steps climbed 96% (74%); duration of cycling 29% (41%]. There was a trend for the increase in performance between successive attempts to become progressively smaller but this was not significant. No effect of placebo on exercise performance was detected. The greatest intersubject range of performance was seen in the step test (14-126 steps) and the least in the walking test (438-1014 m). Significant correlations (p less than 0.01) were observed between performance in all three types of exercise test, but the correlations found between the results of the various tests of exercise performance and the FEV1 and the FVC were either weak (p less than 0.05) or non-significant. Ventilation (VE) and oxygen consumption (VO2) were subsequently measured and compared in eight patients during all three types of exercise test. Both the VE and the VO2 that were achieved in the step test were significantly greater than in either the cycle or the walking test. No patient was able to reach and sustain steady state values of VE and VO2 in the step test, whereas a steady state for both VE and VO2 was reached and sustained by all eight patients in the walking test. It is suggested that at least three practice attempts at any exercise test should be made before the introduction of either placebo or specific pharmacological treatment and that even then it may be necessary to allow for the effects of further repeated testing in the assessment of the results of treatment.