Effects of non-pharmacological sympathetic sudomotor denervation on sweating in humans with essential palmar hyperhidrosis.

OBJECTIVE: Quantitative sweat production and -ionic composition in Essential Hyperhidrosis (EH), and the effects of T2-T3 thoracoscopic sympathicolysis (TS) hereon, are unknown. Standardised pilocarpine iontophoresis sweat tests were performed before and after TS in order to study these issues. DESIGN AND METHODS: Pilocarpine iontophoretic sweat tests measuring maximal sweat production (mg) and sweat Na+, K+ and Cl- concentrations (mMol/L) were performed on both forearms of 10 EH patients, before and six weeks after TS, and in normal volunteers. RESULTS: As compared to normals, preoperative maximal sweat production was 30% higher (199.4 +/- 68.8 (SD) vs. 150.6 +/- 45.6 mg) in EH patients; due to type II error, however, statistical significance was not reached. Na+ and Cl- concentrations were similar, and K+ concentration was slightly lower in EH patients. After TS, sweat production had decreased to equal levels as in normals (149.1 +/- 52.1 mg), whereas the Na+ (from 33.6 +/- 6.9 to 51.0 +/- 6.4 mMol/L), Cl- (from 21.5 +/- 6.6 to 37.2 +/- 7.1 mMol/L) and K+ (from 7.5 +/- 1.3 to 8.6 +/- 2.2 mMol/L) concentrations had increased. CONCLUSIONS: EH patients present 30% higher maximal sweat production at their forearms. This increase may be due to an increased activity of the adrenergic component of sweat gland innervation. The post-TS increase in Na+, Cl- and K+ concentrations suggests that the adrenergic component of sweat gland innervation in itself decreases sweat ion concentrations.

Partial pulmonary sympathetic denervation by thoracoscopic D2-D3 sympathicolysis for essential hyperhidrosis: effect on the pulmonary diffusion capacity.

In patients with essential hyperhidrosis (EH), a pathological condition characterized by increased activity of the upper dorsal sympathetic ganglia D2-D3, anatomical interruption at the D2-D3 level by thoracoscopic sympathicolysis (TS) is a safe and effective treatment. The D2 and D3 ganglia, however, are also in the pathway of sympathetic lung innervation, which may influence the pulmonary diffusion capacity for carbon monoxide (expressed as transfer factor for CO:TLCO, and as transfer coefficient for CO:KCO). We therefore studied the effect of TS on TLCO and KCO in 50 EH patients: compared with pre-operative values, both TLCO (-6.7%, P < 0.001) and KCO (-4.2%, P = 0.002) were significantly decreased at 6 weeks after bilateral TS, an effect which was independent of the smoking status of the patients. In order to explain this phenomenon, the following pharmacological interventions were studied: (1) oral beta 1 + 2-adrenoreceptor blockade with propranolol caused a comparable decrease of TLCO (-6.3%) and KCO (-7.5%) in matched normal subjects, but had no effect on TLCO and KCO in EH patients prior to TS; and (2) subsequent inhalation of the beta 2-adrenoreceptor agonist salbutamol in a dosage suspected to cause alveolar beta-receptor stimulation had no effect on TLCO and KCO, neither in the normal subjects, nor in EH patients (before and after TS). Although the exact mechanism of the TS-induced decrease in TLCO and KCO remains speculative, these findings suggest that they may be related to a beta 1-adrenoreceptor-mediated change in pulmonary capillary membrane permeability, although TS-induced changes in pulmonary blood flow or an interplay of both mechanisms cannot be excluded.

Effects of thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis on bronchial responsiveness to histamine: implications on the autonomic imbalance theory of asthma.

Autonomic nervous system abnormalities in airway control may contribute to the symptoms of asthma, and even to the pathogenesis of bronchial hyperresponsiveness (BHR). Partial pulmonary sympathetic denervation by means of bilateral upper dorsal thoracoscopic D2-D3 sympathicolysis (TS) is an accepted treatment in severe essential hyperhidrosis (EH). The effects of this intervention on BHR are unknown. The objective of this study was to evaluate whether partial pulmonary sympathetic denervation by means of TS has an effect on BHR. Bronchial challenge tests with histamine, enabling the calculation of the provocative dose causing a 20% reduction in FEV1 (PD20 His) were performed 1 day before, and 6 weeks and 6 months after TS in 35 patients with severe EH. In nine patients (including three patients with a previous history of asthma) with pre-operative BHR (defined as PD20 His < 2 mg), mean PD20 His did not change significantly at 6 weeks, nor at 6 months after TS (0.62 +/- 0.33, 0.71 +/- 0.42 and 0.93 +/- 0.65 mg, respectively) although there was a non-significant trend towards an increase in PD20 His at 6 months. Three of the 26 patients (12%) without pre-operative BHR became hyperresponsive after TS, whereas 1 of the 9 patients with pre-operative BHR lost hyperresponsiveness. No patient developed asthma symptoms after TS. Upper dorsal thoracoscopic D2-D3 sympathicolysis performed for the treatment of EH has no significant effects on mean PD20 His and individual loss (11%) or development (12%) of BHR occurs only in a minority of patients.

Percutaneous needle biopsy of localized pulmonary, mediastinal, and pleural diseased tissue with an automatic disposable guillotine soft-tissue needle. Preliminary results.

Percutaneous needle biopsy (PNB) of localized thoracic disease has become a widespread procedure in many institutions. The development of special small caliber needles has increased the diagnostic yield of PNB partly by increasing the amount of tissue from biopsy, often enabling histologic examination. Nevertheless, in a significant number of patients only cytopathologic examination is possible on the retrieved biopsy fragments, necessitating the presence of a trained cytopathologist in the biopsy room. Furthermore multiple biopsy needle passages often are required, increasing the risk for complications such as pneumothorax. We have evaluated the use of a small-caliber tissue biopsy cutting needle, consistently yielding sufficient biopsy tissue for histologic examination. In 25 pleural and mediastinal lesions, which could be biopsied without passage through aerated lung, there was a 93% sensitivity (7% false-negative results) for neoplasm and a 100% accuracy for benign disease. There were no complications. In 32 patients with lesions of 1 cm in diameter or more surrounded with aerated lung tissue, adequate histologic examination was feasible on every biopsy specimen after only one needle passage. There was an 87% sensitivity of PNB in neoplastic disease (13% false-negatives). In the patients with benign disease, there was a 100% accuracy. There was a 15.6% risk for pneumothorax. In only one patient (3%), however, was chest drainage necessary. One patient (3%) had mild hemoptysis. We conclude that percutaneous biopsy of localized pulmonary, pleural, and mediastinal lesions with a new small-caliber automatic guillotine cutting needle is safe and efficient, enabling recovery of sufficient tissue for histologic examination with a single-pass procedure, thus minimizing the risk for pneumothorax, eliminating the need for a cytopathologist in the biopsy room, and shortening the duration of the procedure.

A simplified insertion technique for tracheobronchial silicone stents.

In many patients with central airway obstruction due to extrinsic compression or malacia, insertion of tracheobronchial stents can provide effective and permanent relief. Of the various types of prostheses described, the silicone Dumon-Artemis stents (Medicore, Brussels, Belgium) are probably the most efficient. The use of an elegant and safe specially designed stent introducer system combined with a special bronchoscope is proposed for insertion by Dumon. This combined stent insertion system, however, is relatively expensive and cumbersome, especially for centers where relatively limited numbers of patients are treated. We propose an alternative, simplified insertion technique of silicone Dumon-Artemis stents, which was proven safe and efficient in our series of patients.

Reversibility of upper airway obstruction after levodopa therapy in Parkinson's disease.

Serial flow-volume loops obtained in a 66-year-old patient with Parkinson's disease and recurrent episodes of dyspnea revealed a pattern consistent with upper airway obstruction, reversible after oral intake of levodopa. This observation shows that extrapyramidal involvement of the striated upper airway musculature may limit airflow and cause respiratory symptoms. Persistence of flow oscillations on the flow-volume loop contour after reversal of upper airway obstruction and dyspnea should be considered to reflect upper airway dysfunction with possibly serious consequences.

Flow-volume loop changes reflecting respiratory muscle weakness in chronic neuromuscular disorders.

In order to identify the changes in pulmonary function and in the flow-volume loop due to respiratory muscle weakness, two groups of 10 nonsmokers with stable, chronic neuromuscular disease but without respiratory symptoms were studied: one without (Group 1) and one with (Group 2) respiratory muscle weakness as assessed by measurement of maximal static inspiratory and expiratory pressures. In Group 1, pulmonary function was normal except for increased ratio of one-second forced expiratory volume to forced vital capacity and forced expiratory flow at 25 to 75 percent forced vital capacity, which may reflect increased elastic lung recoil. Group 2 had mild volume restriction, appropriate for the degree of respiratory muscle weakness, and reduced inspiratory and expiratory flow rates. Pulmonary function was significantly more disturbed in Group 2 than in Group 1, and correlated well with maximal static inspiratory and expiratory pressures. Analysis of the flow-volume loop configuration revealed that four parameters describing effort-dependent portions were significantly related to maximal static inspiratory pressure and maximal static expiratory pressure. These parameters were peak expiratory flow, the slope of the ascending limb of the maximal expiratory curve, a drop of forced expiratory flow near residual volume, and forced inspiratory flow at 50 percent of vital capacity. A flow-volume loop score obtained from these four parameters was significantly higher in Group 2 than in Group 1 (2.8 +/- 1.03 versus 1.1 +/- 1.37; p less than 0.01). A flow-volume loop score of 2 or more had 80 percent specificity and 90 percent sensitivity in predicting respiratory muscle weakness in these patients with chronic neuromuscular disease. These data suggest that sensitive assessment of the flow-volume loop configuration as part of routine pulmonary function testing may help to suspect and identify respiratory muscle weakness.

Involvement of upper-airway muscles in extrapyramidal disorders. A cause of airflow limitation.

To identify the site and cause of airflow limitation in patients with parkinsonism, we tested pulmonary function in 27 patients with extrapyramidal disorders. In 24 patients, an abnormal flow-volume loop contour, showing either regular (18 patients) or irregular (6 patients) flow oscillations, was found. On direct fiberoptic visualization of the upper airway, these oscillations corresponded to either rhythmic (4 to 8 Hz) or irregular involuntary movements of glottic and supraglottic structures. Ten patients had physiologic evidence of upper-airway obstruction, which was symptomatic in four. We conclude that the upper-airway musculature is frequently involved in extrapyramidal disorders. This causes upper-airway dysfunction that can be severe enough to limit airflow.