Can heparin cause adult respiratory distress syndrome by a similar mechanism as heparin-associated thrombocytopenia?

A 62-year-old woman who underwent an aortic valve replacement for severe aortic valve stenosis developed postoperative thrombocytopenia and adult respiratory distress syndrome, simultaneously. Both complications resolved promptly after discontinuing heparin therapy. The presence of a heparin-related antiplatelet antibody was detected by in vitro testing. The time course of clinical events suggests the possibility of a heparin-induced, immune-mediated injury to both the pulmonary vascular endothelium and the platelet membrane as an underlying pathophysiologic mechanism.

Work of breathing through different sized endotracheal tubes.

The ability to breathe spontaneously through an endotracheal tube is a usual prerequisite before an intubated patient can have it removed. Other researchers have measured air flow resistance through endotracheal tubes. In this study, we evaluated work of breathing in joules per min and tension-time index while three normal volunteers breathed through different sized endotracheal tubes. Four 27.5-cm endotracheal tubes were used. Subjects breathed with a constant tidal volume of 500 ml. By increasing respiratory frequency, minute ventilation was increased from 5 to 30 L/min. As tube diameter decreased, work and the tension-time index increased. Changes were magnified at higher minute ventilations through the 6- and 7-mm endotracheal tubes, and the tension-time index critical fatigue level of 0.15 was approached or exceeded.

Palliation of bronchogenic carcinoma with 198Au implantation using the fiberoptic bronchoscope.

The majority of cases of bronchogenic carcinoma remain incurable, and many of these patients require palliation of the effects of the tumor on the airway. We have developed a technique for implanting radioactive (198Au) seeds via the fiberoptic bronchoscope. We now retrospectively review the results obtained in 111 procedures in 54 patients. Response was assessed by improvement in symptoms, chest roentgenogram, or bronchoscopic appearance. Nineteen of 29 (66 percent) patients with occluding endobronchial lesions benefitted. Twenty of 22 (91 percent) with hemoptysis improved. All six patients with tracheal lesions benefitted. Two of six (33 percent) patients with nonoccluding endobronchial lesions responded. Complications directly related to the procedure were rarely of major consequence, although a single patient had an exsanguinating hemoptysis four days following the last of multiple implantations. The simplicity, relative safety, and potential wide availability coupled with low equipment costs would suggest an increasing role for this technique in the palliation of endobronchial neoplasms.

Chemiluminescence of lung macrophages and blood leukocytes in sarcoidosis.

A luminol-enhanced chemiluminescence assay was used to measure light elaborated by peripheral blood polymorphonuclear leukocytes (PMNs) and by pulmonary alveolar macrophages (PAMs) from 14 healthy, normal subjects and 16 patients with sarcoidosis. Resting peripheral blood PMNs (incubated only in medium) from patients with sarcoidosis generated substantially more chemiluminescence than PMNs from normal control subjects (p = 0.002). With zymosan stimulation, greater chemiluminescence was produced by PMNs from untreated patients with sarcoidosis than from normal subjects (p less than 0.05), whereas no differences were noted with latex stimulation. Chemiluminescence for resting PAMs was not different between normal subjects and patients with sarcoidosis. However, PAMs from untreated patients with sarcoidosis had higher chemiluminescence with latex particle ingestion than PAMs from normal subjects (p less than 0.05), but no differences in PAM chemiluminescence were found when zymosan was the phagocytic particle. Increased chemiluminescence by PMNs and PAMs from patients with sarcoidosis may reflect phagocyte activation in the disease process.

Evaluation of hemoptysis in patients with a normal chest roentgenogram.

Hemoptysis is a common presenting complaint in patients with pulmonary disease. Although controversial, many clinicians suggest that all patients with hemoptysis should be evaluated with bronchoscopy to exclude the presence of a serious pathologic condition. We reviewed records for an 18-month period, during which 113 patients had hemoptysis as their principal complaint. In all, 26 of the 113 patients had normal chest roentgenograms. All underwent bronchoscopy as part of their evaluations. Results of bronchoscopy in these patients neither altered therapeutic decisions nor led to diagnoses of specific pathologic processes. We conclude that close observation of patients with normal chest roentgenograms who have hemoptysis may be an acceptable clinical approach.

Pulmonary melanoma. Primary vs metastatic.

We report one of the few cases of apparently primary pulmonary melanomas documented by both clinical and autopsy examination. The possibility of spontaneous regression of a melanoma primary in another site after metastasis has occurred may explain some of these cases.

Serial changes in markers of disease activity with corticosteroid treatment in sarcoidosis.

Serial changes in various markers of disease activity with corticosteroid therapy were assessed in 12 patients with active sarcoidosis. After six weeks of treatment with 40 mg daily of prednisone, all but one patient demonstrated symptomatic and radiographic improvement. For the entire patient group, there were corresponding improvements in forced vital capacity, from 59.2 +/- 5.5 to 70.5 +/- 5.3 percent of the predicted value (p less than 0.001, Student paired t test), serum angiotensin-converting enzyme levels, from 66.0 +/- 12.1 to 28.2 +/- 4.0 U/ml (p = 0.003), 67gallium lung scanning scores, from 3.6 +/- 0.2 to 0.8 +/- 0.3 (p less than 0.001), serum gamma globulin levels, from 2.40 +/- 0.2 to 1.5 +/- 0.1 g/dl (p less than 0.001), and erythrocyte sedimentation rate, from 26.8 +/- 2.7 to 14.8 +/- 3.0 mm per hour (p less than 0.001). Changes in percent of bronchoalveolar lavage fluid lymphocytes were less impressive (from 28.7 +/- 4.9 to 21.2 +/- 5.1, p = 0.034), but the geometric mean number of bronchoalveolar lavage fluid-IgG-secreting cells decreased from 23,861 to 3,830 (p = 0.013). Serial evaluations in five patients treated with decreasing doses of alternate-day prednisone for an additional 10 1/2 months indicated that changes in 67gallium lung scanning scores corresponded most closely to the clinical course in five of five patients. Determination of serum angiotensin-converting enzyme levels also closely paralleled the clinical course in four of five patients, whereas the other parameters measured were more variable markers of clinical response. However, abnormalities of bronchoalveolar lavage fluid-IgG-secreting cells often persisted in the absence of clinically evident disease, and the percentages of bronchoalveolar lavage fluid lymphocytes were frequently normal in patients who responded subsequently to corticosteroids. Larger prospective studies are warranted to more extensively evaluate various measurements of disease activity, especially bronchoalveolar lavage fluid analysis, in sarcoidosis.

Defective immunoglobulin secretion in response to pokeweed mitogen in sarcoidosis.

We studied in vitro immunoregulation of immunoglobulin (Ig) secretion in 21 patients with sarcoidosis. While peripheral blood mononuclear cells from normal individuals responded to pokeweed mitogen with a 10-fold or greater increment in Ig-secreting cells, cells from sarcoid patients failed to respond to pokeweed mitogen at any concentration employed (P less than 0.001, Student's t-test, two-tailed). More monocytes were found in sarcoid mononuclear cell preparations (44.8 +/- 2.0% vs 30.4 +/- 1.4% in normal donors, P less than 0.001), but removal of monocytes improved the response to pokeweed mitogen in only four patients. Mononuclear cells from seven of 19 patients suppressed Ig secretion in co-cultures with normal donor cells. Patients exhibiting excessive suppressor cell function were older, with longer standing and less clinically active disease than non-suppressing patients. Monocyte removal reversed the suppression in only four of the suppressor patients, but excessive suppressor monocyte function was later demonstrated in two sarcoid patients whose cells initially did not suppress Ig secretion when cultured with normal cells. While the immunological defects in sarcoidosis may be complex, heterogenous, and dynamic, these data suggest that suppressor monocytes, when present in sarcoidosis, may have developed secondarily.

The use of quantitative sterile brush culture and gram stain analysis in the diagnosis of lower respiratory tract infection.

We prospectively evaluated 55 patients (58 studies) who presented for diagnostic fiberoptic bronchoscopy for the presence of lower respiratory tract infection. A sheathed, nonplugged, sterile brush passed transbronchoscopically under fluoroscopic control was used to retrieve bronchial secretions. These were evaluated using Gram stains, Wright-Giemsa stains, and quantitative bacterial cultures. In 18 studies of patients with known or suspected infection, polymorphonuclear leukocytes and bacterial were easily identifiable on Gram stain, and potential lower respiratory pathogens were recovered in concentrations greater than or equal to 10(6) colony-forming units (cfu)/ml. In 15 control studies of patients with noninfectious lung disease and in 17 studies of patients with suspected lung infection (nine with prior antibiotic therapy), organisms were not seen on Gram stain and in 28/32 studies bacteria were present in concentrations of less than or equal to 10(4) cfu/ml. The remaining eight studies were in patients proved to have active granulomatous disease. These studies establish the ability of a fiberoptic bronchoscopic technique to diagnose bacterial infection in a group of patients presenting difficult diagnostic problems.