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Effects of pursed-lips breathing and expiratory resistive loading in healthy subjects.

To examine the effect of pursed-lips breathing (PLB) on breathing pattern and respiratory mechanics, we studied 11 healthy subjects breathing with and without PLB at rest and during steady-state bicycle exercise. Six of these subjects took part in a second study, which compared the effects of PLB to expiratory resistive loading (ERL). PLB was found to prolong expiratory and total breath durations and to promote a slower and deeper breathing pattern. During exercise, the compensatory increase that occurred in tidal volume was not sufficient to counter the reduction in breathing frequency, causing minute ventilation to be reduced. Although ERL similarly caused minute ventilation and breathing frequency to be decreased, unlike PLB, it produced no change in tidal volume and prolonged expiratory and total breath durations to a lesser extent. PLB and ERL increased the expiratory resistance to a comparable degree, also increasing the expiratory resistive work of breathing and promoting greater expiratory rib cage and abdominal muscle recruitment in response to the expiratory loads. End-expiratory lung volume, which was determined from inspiratory capacity maneuvers, was not altered by PLB; however, with ERL it was increased by 0.20 and 0.24 liter during rest and exercise, respectively. Inspiratory muscle recruitment patterns were not altered by PLB at rest, although small increases in the relative contribution of the rib cage/accessory muscles in conjunction with abdominal muscle relaxation occurred during exercise. Similar trends were observed with ERL. We conclude that, although ERL and PLB induce comparable respiratory muscle recruitment responses, they are not equivalent with respect to breathing pattern changes and effect on end-expiratory lung volume.

Adult↗

Pulmonary function in chronic renal failure patients managed by continuous ambulatory peritoneal dialysis.

The influence of intraperitoneal fluid on pulmonary function was studied in 20 unselected continuous ambulatory peritoneal dialysis (CAPD) patients, all but one of whom had at least one cardiorespiratory disorder. Measurements of pulmonary function were made with the abdomen empty and following the instillation of 2 1 of dialysis fluid (full). Functional residual capacity fell with the peritoneal cavity full, due to decreases in residual volume, and expiratory reserve volume, but there was a corresponding increase in inspiratory capacity. The vital capacity remained unchanged and the total lung capacity fell only slightly. The FEV1, diffusing capacity, and distribution of ventilation were unaltered. These findings can be attributed to an increase in intra-abdominal pressure resulting in elevation of the diaphragm and increased diaphragmatic contractility. We conclude that the instillation of 21 of dialysis fluid in CAPD patients with cardiorespiratory disease does not result in a clinically significant deterioration in these aspects of pulmonary function.

Adult↗

Muscular, respiratory and cardiovascular responses of quadriplegic persons to an F. E. S. bicycle ergometer conditioning program.

Seven quadriplegic subjects participated in F. E. S. bicycle ergometry, three times per week, over an eight week period. Left thigh girth measured at 20 cm above the knee increased from 44.4 cm pre-training to 46.5 cm post-training (p less than 0.05), and right thigh girth increased from 44.3 cm to 46.2 cm (p less than 0.05). Forced vital capacity increased from 3.23 liters (pre-training) to 3.42 liters (post-training) and was significant at the p less than 0.05 level. Forced inspiratory capacity increased for 3.30 liters, pre-training, to 3.42 liters, post-training (p less than 0.05). FEV1 (liters) increased from 2.77, pre-training to 3.07 post-training (p less than 0.05). All three respiratory parameters were 55%-60% of that predicted for normals. Significant changes were also found in resting cardiovascular data. Mean resting heart rate, pre-training, was 51.4 beats per minute compared to 54.5 beats per minute, post-training, (p less than 0.05). Resting cardiac output, pre-training was 4.14 L/min. compared to 4.47 L/min., post-training (p less than 0.05). Further analysis of the cardiovascular data showed that the increased heart rate post-training was associated with a decrease in the P-R interval from 0.186 sec., pre-training to 0.170 sec., post-training (p less than 0.05). Also, the increase in cardiac output, post-training was matched by an increase in the cardiac index from 2.21 L/min./M, pre-training, to 2.36 L/min./M, post-training (p less than 0.05). A statistically significant difference in the heart rate response to the cold pressor test was demonstrated (p less than 0.05) and a similar difference in the amount of heart rate response was seen during the tilt table test (p = 0.05).

Adolescent↗

Respiratory insufficiency in a severe autosomal recessive form of muscular dystrophy.

In a large Sudanese kindred of 176 individuals, 15 children developed a brief respiratory illness in the course of a severe autosomal recessive muscular dystrophy (MD) and eight of them died. The type of MD in this kindred delineates a newly recognized entity which has been described from Sudan, Tunisia, Libya and Qatar . To assess the role of pulmonary insufficiency in the fatal outcome of this disease, pulmonary function was studied in six of the survivors. Values of lung volume were grossly abnormal and revealed a restrictive pattern. The degree of lung volume restriction varied from 50 to 76% of predicted total lung capacity (TLC) and 31-55% of predicted forced vital capacity (FVC). The high FEV1/FVC ratio (80-100%) in all patients excluded airway obstruction and the elevated ratio of residual volume (RV) to TLC (51-68%) reflected loss of inspiratory capacity. FVC showed no correlation with the degree of muscular disability and did not seem to be affected by the mild scoliosis seen in five children. These results are discussed in view of similar studies in a variety of neuromuscular disorders.

Adolescent↗

Physiological changes during symptom recovery from moderate exacerbations of COPD.

Acute exacerbations of chronic obstructive disease (AECOPD) are characterised by worsening dyspnoea that is variably prolonged. In this study, physiological changes during moderate AECOPD were examined and the factors associated with dyspnoea resolution over time were determined. In total, 20 patients experiencing an AECOPD were evaluated within 72 h of initial worsening of symptoms (day 0) with pulmonary function testing, metabolic testing and symptom assessment using the dyspnoea domain of the Chronic Respiratory Disease Questionnaire (CRQ). Treatment was optimised and testing was repeated after 7, 14, 30 and 60 days. At day 0, patients were very short of breath (CRQ-dyspnoea mean+/-SEM 2.4+/-0.3) and showed significant airflow obstruction (forced expiratory volume in one second (FEV1) 41+/-3% predicted) and lung hyperinflation (forced residual capacity (FRC) 164+/-7% pred). By day 60 CRQ-dyspnoea improved to 4.6+/-0.5 (some shortness of breath); FRC and residual volume decreased by 5 and 11%, respectively; inspiratory capacity (IC) and slow vital capacity increased by 18 and 17%, respectively; and FEV1 increased by 18% with no change in FEV1/FVC. Total lung capacity did not change during AECOPD, and thus, changes in IC reliably reflected changes in end-expiratory lung volume. In conclusion, moderate acute exacerbation of chronic obstructive pulmonary disease is characterised by worsening airflow obstruction and lung hyperinflation. Improvement of dyspnoea following acute exacerbations of chronic obstructive pulmonary disease was associated with reduction in lung hyperinflation and consequent increase in expiratory flow rates.

Acute Disease↗

[Importance of air-trapping in patients with COPD. Pathophysiological principle].

Exertional dyspnea is the leading symptom in patients with COPD. The main causes are progressive weakness of skeletal muscles, reduction of diffusing capacity in emphysema and above all dynamic hyperinflation as a result of the collapsibility of bronchioli with expiratory flow limitation. The exercise-induced hyperinflation leads to a reduction of inspiratory capacity. Therefore, patients are unable to increase the minute volume under exercise. The inadequate ventilatory answer to an increased ventilatory drive is perceived as dyspnea. The inhalation of long-acting bronchodilators reduces hyperinflation and increases exercise capacity.

Bronchi↗

An improved in vivo rat model for the study of mechanical ventilatory support effects on organs distal to the lung.

OBJECTIVE: To study the influence of different mechanical ventilatory support strategies on organs distal to the lung, we developed an in vivo rat model, in which the effects of different tidal volume values can be studied while maintaining other indexes. DESIGN: Prospective, randomized animal laboratory investigation. SETTING: University laboratory of Ospedale Maggiore di Milano-Instituto di Ricovero e Cura a Carattere Scientifico. SUBJECTS: Anesthetized, paralyzed, and mechanically ventilated male Sprague-Dawley rats. INTERVENTIONS: Two groups of seven rats each were randomized to receive tidal volumes of either 25% or 75% of inspiratory capacity (IC), calculated from a preliminary estimation of total lung capacity. Ventilation strategies for the two groups were as follows: a) 25% IC, 9.9+/-0.8 mL/kg; frequency, 59+/-4 beats/min; positive end-expiratory pressure, 3.6+/-0.8 cm H2O; and peak inspiratory airway pressure (Paw), 13.2+/-2 cm H20; and b) 75% IC, 29.8+/-2.9; frequency, 23+/-13; positive end-expiratory pressure, 0; peak inspiratory Paw, 29.0+/-3. MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure (invasively monitored) remained well above adequate perfusion pressure values throughout, and no significant difference was seen between the two groups. PaO2, pHa, and PaCO2 values were compared after 60 mins of ventilation and again, no significant difference was seen between the two groups (PaO2, 269+/-25 and 260+/-55 torr; pHa, 7.432+/-0.09 and 7.415+/-0.03; PaCO2, 35.4+/-8 and 32.5+/-2 torr, for the 25% IC and 75% IC groups, respectively). Mean Paws were not different (6.4+/-0.8 cm H2O in the 25% IC groups, and 6.1+/-1.2 in the 75% IC groups, respectively). At the end of the experiment, animals were killed and the liver and kidney isolated, fixed in 4% formalin, cut, and stained for optic microscopy. Kidneys from rats ventilated with 75% IC showed increased Bowman's space with collapse of the glomerular capillaries. This occurred in a greater percentage of rats ventilated with 75% IC (0.67+/-0.2 vs. 0.29+/-0.2, 75% IC vs. 25% IC, respectively; p < .05). Perivascular edema was also present in rats ventilated with 75% IC (p < .05). Morphometric determinations of the empty zones (index of edema) demonstrated a trend toward differences between 75% IC livers and 25% IC (0.14+/-0.05 vs. 0.11+/-0.02, respectively). CONCLUSION: We conclude that it is possible to study the effects of mechanical ventilatory support on organs distal to the lung by means of an in vivo rat model.

Animals↗

Lung function in Indian twin children: comparison of genetic versus environmental influence.

The relative contributions of genetic and environmental components in the variability of lung function measurements were studied in 54 twin pairs. Thirty pairs of monozygote (MZ) twins and 24 pairs of dizygotic (DZ) twins were examined. All measurements were made with 9-litre closed-circuit-type expirographs using standard spirometric techniques, except for peak expiratory flow rate (PFER) which was recorded with a Wright peak flow meter. Within-pair variances for inspiratory capacity (IC), vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), forced mid-expiratory flow (FEV25-75%), forced end-expiratory flow (FEF75-85%), maximum expiratory flow (FEF200-1200ml), forced maximum voluntary ventilation MVVF) and PEFR were significantly smaller (p < 0.01) in MZ twins than in DZ twins. Tidal volume (VT), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), forced expiratory volume in 1 second as a percentage of forced vital capacity (FEV1%), and forced expiratory time (FET) were not significantly different. Within-pair correlations were all higher in MZ than DZ twins. All measurements except for VT and PEFR showed high levels of heritability (23-99%). All measurements were positively and significantly correlated with physical characteristics such as weight, standing height, surface area, arm-span, chest circumference and age, except FEV1% and FET. Residual values adjusted for physical characteristics showed similar results to unadjusted values in most cases. These data indicate that major lung function measurements are possibly influenced more by genetic than environmental factors. Genetically influenced measurements show higher levels of heritability estimates and suggest that genetic determination of lung function is possibly independent of the influence of physical characteristics.

Adolescent↗

Effect of lung inflation on diaphragmatic shortening.

The effect of lung inflation on chest wall mechanics was studied in 11 vagotomized pentobarbital sodium-anesthetized dogs. Diaphragmatic shortening (percent change from initial length at functional residual capacity, %LFRC) and transdiaphragmatic pressure swings (delta Pdi) were compared with control values over a range of positive-pressure breathing that produced a maximum increase in lung volume to 40% of inspiratory capacity. There was no change in the electromyogram of the diaphragm or parasternal intercostals during positive-pressure breathing. delta Pdi and tidal volume (VT) fell to 52 +/- 3.3 and 42.5 +/- 5% (SE) of control. This was associated with a reduction in the initial resting length of 13 +/- 1.9 and 21 +/- 2.2%LFRC (SE) in the costal and crural diaphragms, respectively. Tidal diaphragmatic shortening, however, decreased to 66 +/- 7 and 57 +/- 7 and the mean velocity decreased to 78 +/- 10 and 63 +/- 8% (SE) of control for the costal and crural diaphragms, respectively. We conclude that the reduction in diaphragmatic shortening is the main determinant of the reduced delta Pdi and VT during lung inflation and relate this to what is currently known about diaphragmatic contractile properties.

Animals↗

Effects of fatigue, fiber length, and aminophylline on human diaphragm contractility.

The clinical relevance of methylxanthines as therapeutic agents for improving diaphragmatic contractility is controversial. In a double-blind, placebo-controlled trial, we investigated the effect of aminophylline on the contractility of fresh and fatigued human diaphragm at different lung volumes, and therefore as a function of fiber length. The diaphragmatic contractility of normal subjects was assessed by measurements of transdiaphragmatic pressure changes (Pdi,T) in response to single, bilateral, supramaximal phrenic-nerve shocks during relaxation from total lung capacity (TLC) to functional residual capacity (FRC). Fatigue was induced by resistive breathing. Therapeutic levels of theophylline were reached in all subjects. Under fresh (i.e., nonfatigue) conditions, aminophylline significantly increased Pdi,T at lung volumes above 75% of the inspiratory capacity (IC). Fatigue in the absence of aminophylline caused a disproportionately greater reduction of Pdi,T at high than at low lung volume (J. Appl. Physiol. 1992; 72:1064), which was rapidly reversible with rest. With aminophylline, the disproportionate decrease in diaphragmatic contractility at short fiber lengths was not observed. Aminophylline potentiates diaphragmatic contractility to a proportionately greater extent at short than at long fiber lengths, under both fresh and fatigued conditions. We explain these findings by known effects of muscle shortening, fatigue, and methylxanthines on excitation-contraction coupling mechanisms.

Adult↗

Dynamic hyperinflation during bronchoconstriction in asthma: implications for symptom perception.

OBJECTIVE: The objective of this study was to examine the relationship between respiratory symptom intensity and quality and dynamic lung hyperinflation (DH) during induced bronchoconstriction in asthma. PATIENTS AND METHODS: Subjects with asthma (n = 116) underwent baseline spirometry and lung volume measurement followed by high-dose methacholine challenge testing (MCT) [maximum decrease in FEV(1) of 50% from baseline]. Dyspnea intensity (Borg scale) was measured after each dose of methacholine. Qualitative descriptors of breathlessness and functional residual capacity (FRC) were measured at the doses nearest to the provocative concentration of methacholine causing a 20% fall in FEV (PC(20)) and at the highest dose of methacholine (maximum response). RESULTS: FEV(1) decreased by 24.7 +/- 0.7% (mean +/- SEM) at the dose nearest to PC(20) and by 46.1 +/- 1.1% at maximum response. Inspiratory capacity decreased by 0.62 +/- 0.04 L at the dose nearest to PC(20) and 1.06 +/- 0.06 L at maximum response. The descriptor clusters "inspiratory difficulty," "chest tightness," "unsatisfied inspiration," and "work" were selected at the dose nearest to PC(20) but were more frequently selected at maximum response (p < 0.0001). Individuals who reported chest tightness at maximum response had greater airflow obstruction and higher FRC (percentage of predicted) than those who did not report chest tightness. CONCLUSIONS: Four dominant qualities of dyspnea in asthma (inspiratory difficulty, chest tightness, unsatisfied inspiration, and work) were reported early in the course of MCT and evolved in parallel, becoming more prevalent at maximum response. Significant DH accompanied even mild bronchoconstriction during MCT in asthma, making it difficult to separate mechanisms of chest tightness from other dominant respiratory sensations.

Adult↗

Exercise training improves exertional dyspnea in patients with COPD: evidence of the role of mechanical factors.

BACKGROUND: To our knowledge, no data have been reported on the effects of exercise training (EXT) on central respiratory motor output or neuromuscular coupling (NMC) of the ventilatory pump, and their potential association with exertional dyspnea. Accurate assessment of these important clinical outcomes is integral to effective management of breathlessness of patients with COPD. MATERIAL AND METHODS: Twenty consecutive patients with stable moderate-to-severe COPD were tested at 6-week intervals at baseline, after a nonintervention control period (pre-EXT), and after EXT. Patients entered an outpatient pulmonary rehabilitation program involving regular exercise on a bicycle. Incremental symptom-limited exercise testing (1-min increments of 10 W) was performed on an electronically braked cycle ergometer. Oxygen uptake (O(2)), carbon dioxide output (CO(2)), minute ventilation (E), time, and volume components of the respiratory cycle and, in six patients, esophageal pressure swings (Pessw), both as actual values and as percentage of maximal (most negative in sign) esophageal pressure during sniff maneuver (Pessn), were measured continuously over the runs. Exertional dyspnea and leg effort were evaluated by administering a Borg scale. RESULTS: Measurements at baseline and pre-EXT were similar. Significant increase in exercise capacity was found in response to EXT: (1) peak work rate (WR), O(2), CO(2), E, tidal volume (VT), and heart rate increased, while peak exertional dyspnea and leg effort did not significantly change; (2) exertional dyspnea/O(2) and exertional dyspnea/CO(2) decreased while E/O(2) and E/CO(2) remained unchanged. The slope of both exertional dyspnea and leg effort relative to E fell significantly after EXT; (3) at standardized WR, E, and CO(2), exertional dyspnea and leg effort decreased while inspiratory capacity (IC) increased. Decrease in E was accomplished primarily by decrease in respiratory rate (RR) and increase in both inspiratory time (TI) and expiratory time; VT slightly increased, while inspiratory drive (VT/TI) and duty cycle (TI/total time of the respiratory cycle) remained unchanged. The decrease in Pessw and the increase in VT were associated with lower exertional dyspnea after EXT; (4) at standardized E, VT, RR, and IC, Pessw and Pessw(%Pessn)/VT remained unchanged while exertional dyspnea and leg effort decreased with EXT. CONCLUSION: In conclusion, increases in NMC, aerobic capacity, and tolerance to dyspnogenic stimuli and possibly breathing retraining are likely to contribute to the relief of both exertional dyspnea and leg effort after EXT.

Carbon Dioxide↗

Orthopnea and tidal expiratory flow limitation in chronic heart failure.

BACKGROUND: Tidal expiratory flow limitation (FL) is common in patients with acute left heart failure and contributes significantly to orthopnea. Whether tidal FL exists in patients with chronic heart failure (CHF) remains to be determined. PURPOSES: To measure tidal FL and respiratory function in CHF patients and their relationships to orthopnea. METHODS: In 20 CHF patients (mean [+/- SD] ejection fraction, 23 +/- 8%; mean systolic pulmonary artery pressure [sPAP], 46 +/- 18 mm Hg; mean age, 59 +/- 11 years) and 20 control subjects who were matched for age and gender, we assessed FL, Borg score, spirometry, maximal inspiratory pressure (Pimax), mouth occlusion pressure 100 ms after the onset of inspiratory effort (P(0.1)), and breathing pattern in both the sitting and supine positions. The Medical Research Council score and orthopnea score were also determined. RESULTS: In the sitting position, tidal FL was absent in all patients and healthy subjects. In CHF patients, Pimax was reduced, and ventilation and P(0.1)/Pimax ratio was increased relative to those of control subjects. In the supine position, 12 CHF patients had FL and 18 CHF patients claimed orthopnea with a mean Borg score increasing from 0.5 +/- 0.7 in the sitting position to 2.7 +/- 1.5 in the supine position in CHF patients. In contrast, orthopnea was absent in all control subjects. The FL patients were older than the non-FL patients (mean age, 63 +/- 8 vs 53 +/- 12 years, respectively; p < 0.03). In shifting from the seated to the supine position, the P(0.1)/Pimax ratio and the effective inspiratory impedance increased more in CHF patients than in control subjects. The best predictors of orthopnea in CHF patients were sPAP, supine Pimax, and the percentage change in inspiratory capacity (IC) from the seated to the supine position (r(2) = 0.64; p < 0.001). CONCLUSIONS: In sitting CHF patients, tidal FL is absent but is common supine. Supine FL, together with increased respiratory impedance and decreased inspiratory muscle force, can elicit orthopnea, whom independent indicators are sPAP, supine Pimax and change in IC percentage.

Disease Progression↗

Respiratory muscle overloading and dyspnoea during bronchoconstriction in asthma: protective effects of fenoterol.

Whether, and to what extent, beta 2-agonists protect against respiratory muscle overloading and breathlessness during bronchoconstriction remains to be defined in patients with asthma. In a double blind placebo-controlled study, 100 micrograms of fenoterol were administered to six stable asthmatics before a bronchial provocation test, performed by inhaling doubling concentrations of histamine from a Devilbiss 646 nebulizer. We recorded breathing pattern (tidal volume VT, inspiratory time TI, total time of the respiratory cycle TTOT), inspiratory capacity (IC), dynamic pleural pressure swing (Pplsw), total lung resistance (RL) and FEV1. VT was expressed both in actual values and as % of IC. Changes in VT (%IC) during histamine inhalation reflected changes in dynamic end-inspiratory lung volume (EILV). Pplsw was expressed as % of maximal (the most negative in sign) pleural pressure, obtained under control conditions during a sniff manoeuvre (Pplsn). Pplsw (%Pplsn) is an index of inspiratory muscle effort. The test ended when the concentration of histamine which caused a decrease in FEV1 of > or = 40% post-saline was reached. Dyspnoea rating was scored by a modified Borg scale. At the ultimate degree of bronchoconstriction (UDB) with histamine: (i) decrease in FEV1 was similar after placebo and fenoterol, while increase in RL was lower after fenoterol (P < 0.005); (ii) VT(%IC) increased less after fenoterol (P < 0.027); (iii) increases in Pplsw (%Pplsn) was lower after fenoterol (P < 0.001); (iv) delta Borg (from saline) was lower (P < 0.01) after fenoterol; (v) differences in delta Borg, from placebo to fenoterol, related to concurrent changes in VT(%IC) (r2 = 0.67). In conclusion, at UDB 100 micrograms of fenoterol produced a beneficial effect on the degree of inspiratory muscle loading and breathlessness, an effect greater than it would be expected from measuring FEV1 alone.

Adrenergic beta-Agonists↗

[End inspiratory lung volumes as the limiting factor in PEEP ventilation].

In 17 patients requiring artificial ventilation expiratory pressure-volume curves (VPE) were plotted all over the inspiratory capacity (IC) between total lung capacity (TLC) and functional residual capacity (FRC). Then patients were ventilated with PEEP of 0, 5, 10 and 15 cmH2O for 30 min. The volume excursions with known PEEP were displayed graphically into the VPE to determine the position of end-inspiratory volume within the IC. The steep, quasi-linear part of each VPE was flattening exponentially against TLC in the upper part of the curve. This "overdistension range" was found to be identical with the upper 40% of IC. Heavy side-effects of PEEP ventilation were never seen before the inspiratory volume excursion had reached this upper 40% of IC. If this was the case, the following observations were made: 1. Static compliance (Cst) decreased by more than 10% in all cases. 2. Pulmonary vascular resistance (PVR) increased by more than 20% in 12 cases. 3. Cardiac index (CI) decreased by more than 15% in 12 cases. 4. The alterations observed in Cst, PVR and CI increased rapidly, when the lungs were further distended, and were well correlated parabolically to the position of end-inspiratory volume within IC. --5 patients failed to show important circulatory alterations. It is concluded that overdistension-related side-effects of PEEP on respiratory mechanics and circulation do not occur before the linear part of the pressure-volume curve has been exceeded by hyperinflation. For the first adjustment of controlled ventilation at least the upper third of IC should be avoided.

Adolescent↗

Single breath versus panting technique in salbutamol delivery through a 750 mL spacing device.

Spacing devices have been widely advocated for asthmatic patients having difficulty actuating metered aerosols and co-ordinating inspiration. Studies have generally supported the slow inspiration/breath hold technique. This requires conscious respiratory control. Such control is often not possible in young children; consequently panting techniques are widely recommended. The panting technique has not been studied. The aim of this study was to compare the bronchodilator effectiveness of panting and the single breath maneuver, each followed by a breath hold, and each at functional residual capacity (FRC), using a Volumatic Space. The study design was a randomly allocated cross-over assessment of bronchodilator response for each technique. The drug dosage was controlled by limiting the inspired volumes of gas (single and cumulative) to the pretested inspiratory capacity. Two hundred micrograms of salbutamol was delivered into the spacer. Twenty-one patients were entered in the study and 15 (mean age +/- SD = 10.9 +/- 3.3 years) completed the protocol. There was no significant difference in bronchodilator response between the two groups. We conclude that the panting and the single breath techniques are equally effective in children of this age group.

Adolescent↗

Lung hyperinflation and flow limitation in chronic airway obstruction.

We reasoned that if flow limitation plays an important role in lung hyperinflation, then bronchodilatation should be associated with a decrease of functional residual capacity (FRC) only in subjects breathing under conditions of flow limitation. This hypothesis was tested in 33 subjects with chronic airway narrowing due to asthma or chronic obstructive pulmonary disease (COPD). Flow limitation during tidal breathing was inferred from the impingement of the tidal flow-volume loop on the flow recorded during submaximally forced expiratory manoeuvres initiated from end-tidal inspiration. At baseline, flow limitation during tidal breathing was present in seven asthmatic (Group 1) and eight COPD subjects (Group 2), but absent in 11 asthmatic (Group 3) and seven COPD subjects (Group 4). FRC (mean+/-SEM) was similar in the four groups (range 117+/-7 to 134+/-6% of predicted). Inhalation of salbutamol (200 microg) caused significant increments of the forced expiratory volume in one second (FEVI) (range 6+/-1 to 21+/-8% of baseline) and forced expiratory flows at 30% of baseline forced vital capacity (V'30) (range 58+/-13 to 235+/-93% of baseline) in all groups. In groups with flow limitation during tidal breathing at baseline the FRC measured by plethysmography decreased significantly (12+/-2% in Group 1, and 9+/-2% in Group 2), and the inspiratory capacity (IC) measured by spirometry increased significantly (17+/-3% in Group 1 and 7+/-3% in Group 2). This was associated with flow limitation disappearing at the volume of baseline end-tidal expiration. In Groups 3 and 4 neither FRC nor IC changed significantly. The breathing pattern was not modified in any group after salbutamol. These findings suggest that flow limitation may contribute to generation of lung hyperinflation both in asthma and chronic obstructive pulmonary disease. We speculate that the increment of functional residual capacity could be triggered by dynamic airway compression downstream from the flow-limiting segment.

Adult↗

Pulmonary function and morbidity in 40 adult patients with cystic fibrosis.

Pulmonary function and cardiopulmonary complications were studied in a group of 40 patients with cystic fibrosis who reached the age of 25 years. Mean values for vital capacity (VC), functional residual capacity, residual volume (RV), the ratio of RV over total lung capacity (RV/TLC), conductance, and the ratio of the forced expiratory volume in one second over VC were abnormal. There was a variable pattern of progression from patient to patient. The men differed from the women only in that they had a significantly larger TLC and inspiratory capacity than the women. The resultant preservation of VC may have an advantage for survival in those patients in whom it is observed. Pseudomonas aeruginosa was encountered with increasing frequency with age. Massive hemoptysis did not result in early death. The occurrence of rightsided heart failure secondary to cor pulmonale, with or without respiratory failure, was a poor prognostic sign.

Adolescent↗