Pulmonary section development influences general medical house officer interests and ABIM certifying examination performance.

To determine whether sectional development in pulmonary and critical care medicine influences medical house officers' (HO) interests and knowledge about respiratory medicine, we reviewed HO performance on the American Board of Internal Medicine (ABIM) certifying examination during 4 years before and 5 years after reorganization of our section. After major changes in the program and introduction of new educational opportunities, HOs more often selected pulmonary consultation electives (68.6% vs 47.8%; p = 0.009) and entered pulmonary fellowships after completion of residency training (12% vs 3%; p = 0.047). Total ABIM examination score did not change, but performance on its respiratory disease component improved from a median national percentile score of 48.5% (1986 to 1989) to 80.0% (1990 to 1994) (p = 0.0365). In relation to other specialty component scores, the rank of the respiratory disease percentile improved from the lowest specialty score to the highest. ABIM examination scores correlated with the cumulative faculty effort directed toward HO teaching (r = 0.70; p = 0.04) and the total number of clinical teachers (faculty and fellows) interacting with HOs (r = 0.73; p = 0.02). Academic development in pulmonary/critical care faculty has an important influence on medical HO interests in and knowledge of that discipline. Plans for the future structure of academic pulmonary/critical care sections must take into account this impact on the training of generalists. Although institutional priorities, resources, and shifting external forces will define how, where, and by whom respiratory medicine will be taught, an appropriate number of faculty members and sufficient commitment of their time to HO education must be preserved.

Aspiration and acute lung injury.

Aspiration is a common clinical entity whose consequences range from the relatively benign to fulminant acute respiratory failure and death. Clinical situations in which airway protection is lost or compromised predispose patients to aspiration. Treatment of aspiration, while generally supportive, depends in part upon the material aspirated and the resulting clinical syndrome. When mechanical ventilatory support is required, the avoidance of iatrogenic complications, including worsening lung injury, becomes especially important. Preventative measures, either to minimize the chances of aspiration, or to reduce the potential for injury consequent to aspiration may be highly effective in reducing the incidence of aspiration syndromes.

Increased antioxidant activity in bronchoalveolar lavage fluid after acute lung injury in anesthetized sheep.

OBJECTIVE: To determine if bronchoalveolar lavage fluid is a more potent antioxidant after acute lung injury in a sheep model compared with the baseline condition. DESIGN: Nonrandomized, controlled study, with repeated measures. SETTING: University research laboratory. SUBJECTS: Seven healthy adult sheep (25 to 50 kg) were studied with five experimental sheep and two control sheep. INTERVENTIONS: Sheep with lung-lymph fistulas were used to study the antioxidant activity of serum, lymph, and bronchoalveolar lavage fluid, both at baseline and after the iv infusion of endotoxin and subsequent induction of acute lung injury. Antioxidant activity was measured, and it reflects the ability of serum, lymph, and bronchoalveolar lavage fluid to inhibit lipid peroxidation. MEASUREMENTS AND MAIN RESULTS: When compared at several volumes, bronchoalveolar lavage fluid after acute lung injury was a more potent inhibitor of lipid peroxidation than bronchoalveolar lavage fluid at baseline. In contrast, antioxidant activity in both serum (69.6 +/- 4.5% vs. 47.2 +/- 4.6%; p = .001) and lymph (45.0 +/- 2.3% vs. 31.9 +/- 1.2%; p = .001) decreased with acute lung injury. CONCLUSIONS: These findings suggest that the alveolar fluid after acute lung injury possesses enhanced antioxidant activity that is likely due to the influx of serum proteins. Thus, the high permeability pulmonary edema of acute lung injury, while detrimental to gas exchange, may be beneficial in preventing further oxidant-mediated lung injury.

Antioxidant activity of bronchoalveolar lavage fluid in the adult respiratory distress syndrome.

Bronchoalveolar lavage (BAL) fluid from normal subjects is a potent inhibitor of lipid peroxidation. This antioxidant activity (AOA) of BAL fluid is primarily due to the serum proteins transferrin and ceruloplasmin. In the adult respiratory distress syndrome (ARDS), there is an influx of protein-rich edema fluid into the alveolar space that may increase antioxidant activity and provide protection against further oxidant-mediated lung injury. To test this hypothesis, the AOA of BAL fluid was measured in patients with ARDS (n = 11) and normal subjects (n = 12). When compared with normal subjects, BAL fluid from ARDS patients had a significantly higher concentration of total protein (2,536.8 +/- 408.2 micrograms/ml vs. 77.3 +/- 7.0 micrograms/ml, P less than 0.005). When compared at several volumes, BAL fluid from ARDS patients was a more potent inhibitor of lipid peroxidation than BAL fluid from normals. In addition, when AOA was determined on equal milligram amounts of BAL fluid protein from ARDS patients and normal subjects, ARDS BAL fluid protein had a significantly higher AOA. Consistent with its higher AOA, ARDS BAL fluid contained increased concentrations of both transferrin (77.8 +/- 15.3 micrograms/ml vs. 2.78 +/- 0.3 micrograms/ml, P less than 0.05) and ceruloplasmin (36.5 +/- 5.6 micrograms/ml vs. 0.26 +/- 0.02 micrograms/ml, P less than 0.005) compared with normal subjects. The importance of both ceruloplasmin and transferrin in the enhanced AOA of ARDS BAL fluid was further demonstrated by studies that showed a significant decrement in AOA when the antioxidant functions of these two proteins were selectively blocked.(ABSTRACT TRUNCATED AT 250 WORDS)

Deficiency of alveolar fluid glutathione in patients with sepsis and the adult respiratory distress syndrome.

The adult respiratory distress syndrome (ARDS) is a devastating clinical illness characterized by refractory hypoxemia and high-permeability pulmonary edema. Reactive oxygen species such as hydrogen peroxide and hypochlorous acid may play a key role in the pathogenesis of the acute lung injury. Glutathione (GSH) is a tripeptide that is able to react with and effectively neutralize oxidants such as hydrogen peroxide and hypochlorous acid. The present study found that the alveolar epithelial lining fluid of patients with ARDS was deficient in total GSH compared to normal subjects (21.7 mumols +/- 7.8 mumols vs 91.8 mumols +/- 14.5 mumols; p = 0.002). In addition, if GSH was measured in unconcentrated bronchoalveolar lavage (BAL) fluid and indexed to total BAL protein, there was also a deficiency in patients with ARDS compared to normal subjects (0.004 +/- 0.003 nmol of GSH per microgram of total protein vs 0.026 +/- 0.005 nmol of GSH per microgram of total protein; p = 0.002). Since patients with ARDS are subjected to an increased burden of oxidants in the alveolar fluid, principally released by recruited neutrophils, this deficiency of GSH may predispose these patients to enhanced lung cell injury.