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Performance of the large-reservoir oxygen mask (Ventimask).

The performance of large-reservoir Venturi masks ('Ventimask') giving nominal inspired oxygen (O2) concentrations ranging from 24% to 60% was assessed in a face model, in six normal subjects, and in ten patients with severe chronic airflow obstruction at the O2 flow rates recommended. Instantaneous oxygen concentrations were measured with a mass spectrometer ('Centronics MGA200') and volume-weighted to give mean inspired concentrations (FiO2). In human studies volume-weighting was achieved by simultaneous measurement of tidal volume from chest and abdominal motion by the use of a respiratory inductance plethysmograph ('Respitrace'). Reinspiration of dead space from the mask was assessed by measuring FiCO2, which varied from 0.2 to 0.4% (normals) and was 0.6 +/- 0.4% in patients. In normal subjects and patients breathing at rest the FiO2% in 24, 28, 35, and 40% ventimasks was within 1.9% absolute of nominal (range-1.2 to +1.9%) but the 60% mask read low (50.3%). Various factors can make FiO2 less than nominal but the human and model studies indicated that reinspiration of dead space from the mask was more important than hyperventilation. In tachypnoeic patients (frequency greater than 30/min), the O2 flow should be increased to 50% above recommended.

Aged↗

Reversible fraction of airway resistance in healthy children of areas with different levels of atmospheric pollutants.

Reversible fraction of airway resistance (delta Raw) has been defined as the difference between airway resistances (Raw) before and after inhalative treatment with ipratropium-bromide (Atrovent) aerosols in healthy subjects. We examined delta Raw in children between 6-8 years of age living in areas with different air qualities. We found small but statistically significant (p less than 0.1) greater delta Raw for children of higher polluted areas. This could indicate that children of polluted areas possessed higher bronchial smooth muscle tone.

Age Factors↗

In Check Dial: accuracy for Diskus and Turbuhaler.

OBJECTIVE: The In Check Dial was developed to evaluate whether a patient is able to generate an adequate peak inspiratory flow (PIF) through a certain inhalation device. The inhalation profile recorder (IPR) is a calibrated instrument that measures flows through Diskus and Turbuhaler in our research setting. The aim of this study was to compare the PIFs of patients when inhaling through a Diskus or Turbuhaler connected with the IPR (PIF_diskus and PIF_TH) to the flows through the corresponding orifices of the In Check Dial (Diskus_In Check and TH_In Check). METHODS: Twenty-four stable asthma and twenty-one chronic obstructive pulmonary disease (COPD) patients inhaled, on two separate occasions, in randomised order, via the Diskus or Turbuhaler connected with the IPR. Subsequently, patients inhaled through the In Check Dial using the orifices of Diskus or Turbuhaler. RESULTS: The difference between Diskus_In Check and PIF_diskus was 3.9 (11.9)l/min (P=0.038). The difference between TH_In Check and PIF_TH was 3.5 (10.6) l/min (NS). All Diskus- and Turbuhaler-inhalations were performed with the minimum required flow of 30 l/min. However, four COPD patients inhaled with the non-optimal flow (<60 l/min) through the Turbuhaler. The In Check Dial did not indicate two of them. CONCLUSION: Measuring PIF through Diskus and Turbuhaler using the IPR and the In Check Dial, respectively shows a disagreement of 3.9l/min. A disagreement of 3.5l/min was found for the Turbuhaler. The In Check Dial did not identify two of four patients as 'non-optimal' users.

Asthma↗

[Surgery for emphysema: recent advances].

INTRODUCTION: The treatment of chronic obstructive pulmonary disease has progressed considerably over the past 40 Years but, for most patients with advanced disease, medical management does not often produce more than limited benefits, particularly in terms of quality of life. STATE OF ART: Over the last decade the surgical treatment of emphysema, which was previously limited to bullectomy, has seen important developments: for carefully selected patients lung Volume reduction surgery and lung transplantation now offer the possibility of real symptomatic improvement and even prolonged survival. Thanks to the thousands of patients who have received these treatments our understanding of the pathophysiological mechanisms, surgical techniques, risks and benefits, medium and long-term results, and selection criteria has improved considerably. PERSPECTIVES AND CONCLUSIONS: This review summarises the most important aspects of these developments and discusses the role of Volume reduction and lung transplantation in the treatment of advanced emphysema.

Cost-Benefit Analysis↗

Pressure support ventilation in adult respiratory distress syndrome: short-term effects of a servocontrolled mode.

PURPOSE: To assess the short-term effects of pressure support ventilation in adult respiratory distress syndrome (ARDS), we studied 17 patients with moderate to severe ARDS using mandatory rate ventilation (MRV), a servocontrolled mode of PSV having respiratory rate as the targeted parameter. MATERIALS AND METHODS: Based on the duration of ARDS, the patients were divided into two groups: Group 1, early ARDS (duration up to 1 week), 10 patients; Group 2, intermediate ARDS (duration between 1 and 2 weeks). The patients were initially ventilated with assisted mechanical ventilation then with MRV, and finally with controlled mechanical ventilation. After a 20-minute period allowed for stabilization in each mode, ventilatory variables, gas exchange, hemodynamics, and patient's inspiratory effort were evaluated. RESULTS: During MRV blood gases, airway pressures and hemodynamic variables remained within acceptable limits in all patients. Compared with assisted mechanical ventilation, during MRV, patients of group 1 decreased their VT and V (from 0.64 +/- 0.04 to 0.42 +/- 0.03 L/sec) and increased their TI/TT (from 0.39 +/- 0.03 to 0.52 +/- 0.03). f did not change. PAO2 - PaO2 and QS/QT decreased (from 306 +/- 16 to 269 +/- 15 mm Hg, and from 20.2 +/- 1.4 to 17.5 +/- 1.1, respectively), while PaCO2 increased (from 44 +/- 3 to 50 +/- 3 mm Hg). On the contrary, patients of group 2 increased their VT (from 0.69 +/- 0.02 to 0.92 +/- 0.09 L), decreased their f (from 22.3 +/- 0.5 to 19.3 +/- 0.3 b/min), although they did not change their V and TI/TT. PAO2 - PaO2 and QS/QT remained stable. PaCO2 diminished (from 39 +/- 3 to 34 +/- 3 mm Hg). Pressure support level was higher in group 2 than in group 1 (29.4 +/- 3.0 v 19.8 +/- 2.9 cm H2O). CONCLUSIONS: We conclude that (1) PSV delivered by MRV may adequately ventilate patients with moderate to severe ARDS, preserving gas exchange and hemodynamics, at least for the short period tested; (2) early and intermediate ARDS respond in a different manner to MRV in terms of breathing pattern, gas exchange, and level of pressure assistance; and (3) patients with early ARDS are those who have an improvement in intrapulmonary oxygenation probably due, at least in part, to alveolar recruitment augmented by active diaphragmatic contraction.

Adult↗

Inspiratory pressure threshold training for glottal airway limitation in laryngeal papilloma.

A single-subject design was used to determine if inspiratory pressure threshold training increases inspiratory muscle strength and reduces the sensation of dyspnea during exercise and speech. The subject was a 23-year-old female with congenital juvenile papilloma which has been in remission for 10 years. A 4-week inspiratory muscle training program was implemented using an inspiratory pressure threshold trainer. The pressure threshold of the trainer was set by the experimenter. The pressure threshold setting of the trainer was based on a percentage of the subject's maximum inspiratory pressure measured prior to training. The average range of the pressure threshold was 40 to 70 cmH2O. In order for inspiratory air to flow, the subject generated inspiratory pressure, independent of airflow rate. Maximum inspiratory pressure (MIP) was the dependent variable used as the index of inspiratory muscle strength. Exercise dyspnea was a dependent variable rated by the subject during a progressive treadmill test. Dyspnea associated with speech was rated following production of a comfortable and loud speech task. MIP increased by 57% following the training program with a 2-scale point reduction in the perception of dyspnea during exercise. Dyspnea during loud speech decreased from moderate to mild. The changes in dyspnea, both during exercise and speech, are directly related to inspiratory muscle strengthening. The results suggest that inspiratory muscle training may improve respiratory related function in patients with restrictive upper airway disorders.

Adult↗

Stroboscopic and acoustic measures of inspiratory phonation.

Inspiratory phonation (IP) is the production of voice as air is taken into the lungs. Although IP is promoted as a laryngeal assessment and voice treatment technique, it has been described quantitatively in very few speakers. This study quantified changes in laryngeal adduction, fundamental frequency, and intensity during IP relative to expiratory phonation (EP). We hypothesized that IP would increase laryngeal abduction and fundamental frequency. The experiment was a within-subjects, repeated measures design with each subject serving as her own control. Participants were 10 females (ages 19-50 years) who underwent simultaneous transoral videostrobolaryngoscopy and acoustic voice recording. We found that membranous vocal fold contact decreased significantly during IP relative to EP, while the trends for change of ventricular fold squeeze during IP varied across individuals. Vocal fundamental frequency increased significantly during IP relative to EP, but intensity did not vary consistently across conditions. Without teaching or coaching, changes that occurred during IP did not carry over to EP produced immediately following IP within the same respiratory cycle.

Adult↗

Reproducibility of response to nasal lysine-aspirin challenge in patients with aspirin-induced asthma.

BACKGROUND: Peak nasal inspiratory flow (PNIF) and acoustic rhinometry objectively measure the effects of nasal provocation testing. Although the latter is conventionally used in nasal lysine-aspirin challenge, use of the former in aspirin-induced asthma (AIA) has never been evaluated. OBJECTIVE: To evaluate the reproducibility of PNIF and acoustic rhinometry following nasal lysine-aspirin challenge in AIA. METHODS: Fourteen patients with a clear-cut history of AIA underwent nasal lysine-aspirin challenge at 2 separate visits 1 week apart. Both PNIF and minimum cross-sectional area (MCA) were measured using acoustic rhinometry for 120 minutes following standard nasal lysine-aspirin challenge (25 mg). RESULTS: Prechallenge values were not significantly different at visit 1 vs visit 2 for mean [SEM] PNIF (128 [13] vs 127 [9] L/min) and MCA (6.89 [0.51] vs 6.94 [0.57] cm2). The mean (SEM) maximum percent PNIF change from baseline for visit 1 and visit 2 was -42 (5) and -42 (6), respectively, and the mean (SEM) average percent PNIF change from baseline was -25 (4) and -25 (6), respectively. The mean (SEM) maximum percent MCA change from baseline for visit 1 and visit 2 was -49 (4) and -48 (3), respectively, and the mean (SEM) average percent MCA change from baseline was -25 (8) and -24 (4), respectively. Coefficients of variation for maximum and average responses were 2.3% and 6.5%, respectively, for PNIF and 7.4% and 16.1% for MCA. CONCLUSIONS: Measurement of PNIF following nasal lysine-aspirin challenge is a simple and reproducible alternative to acoustic rhinometry, with maximum response being a more reproducible outcome measure than average response.

Adrenal Cortex Hormones↗

A randomized comparison of the effects of budesonide and mometasone furoate aqueous nasal sprays on nasal peak flow rate and symptoms in perennial allergic rhinitis.

BACKGROUND: Using conventional methods, it has been difficult to show differences in efficacy between intranasal corticosteroids in perennial rhinitis. OBJECTIVE: To compare the effects of budesonide and mometasone on nasal symptoms and nasal airflow in perennial allergic rhinitis. METHODS: Four hundred thirty-eight patients (age > 18 years old) were randomized to budesonide, 256 microg or 128 microg, mometasone furoate 200 microg, or placebo, once daily for 4 weeks. Efficacy was evaluated by nasal index score (NIS; the sum of scores for blocked nose, runny nose, and itchy nose/sneezing) and peak nasal inspiratory flow (PNIF). RESULTS: All three active treatments significantly reduced the NIS compared with placebo. There was no significant difference between the treatments, although the effect of budesonide, 256 microg, tended to be greater than that of the other regimens. PNIF was significantly improved with all three active treatments: the effect of budesonide 256 microg on morning and evening PNIF was significantly greater than that of mometasone furoate and 128 microg budesonide. Budesonide had a rapid onset of action, showing a significantly greater effect on evening PNIF than mometasone furoate during the first 10 days. For all active treatments, significant improvements in NIS were seen within 4 hours of the first dose. All three treatments were well tolerated. CONCLUSION: The objective parameter PNIF was capable of demonstrating greater efficacy of budesonide 256 microg compared with budesonide 128 microg and mometasone furoate 200 microg, whereas the combined nasal symptom score could only distinguish active treatment from placebo.

Administration, Intranasal↗

Subjective and objective markers of treatment response in patients with seasonal allergic rhinitis.

BACKGROUND: Although there is a recognized association between upper and lower allergic airways disease, it is unknown how seasonal allergic rhinitis (SAR) therapy will effect sensitive markers of airway function in patients with no history of asthma. OBJECTIVE: To prospectively evaluate subjective and objective markers of treatment response in 26 patients with SAR who have been screened to exclude a diagnosis of asthma. METHODS: The patients' usual treatment, with antihistamine alone (n = 13) or in combination with intranasal corticosteroid (n = 13), was withheld for 1 week to achieve a baseline and then resumed. Measurements were made after baseline and after 2 and 4 weeks of treatment for nasal peak inspiratory flow rate (nPIFR); airways resistance (Raw) and specific conductance (sGaw); and nasal nitric oxide (NO). Patients reported their symptom (nasal, throat and eye) scores, daily activity scores, and ocular sodium cromoglycate usage over the preceding 24 hours. RESULTS: Compared with baseline, there were significant (P < .05) improvements with nPIFR, symptom scores and cromoglycate usage at 2 and 4 weeks of treatment. There was no significant suppression for NO at 2 or 4 weeks. There was a significant correlation between nPIFR and nasal symptoms (r = -0.52, P < .001). After 4 weeks of treatment there were significant (P < .05) improvements in sGaw (143.3% predicted) and Raw (91.6% predicted) compared with baseline (sGaw: 111.8%, Raw: 104.2% predicted). CONCLUSION: Treatment of SAR improves upper and lower airway parameters but not NO. Nasal PIFR correlates significantly with nasal symptoms.

Adult↗

Reproducibility of twitch and sniff transdiaphragmatic pressures.

Twitch transdiaphragmatic pressure (Tw Pdi) measured with magnetic stimulation of the phrenic nerve is used to follow up patients and to assess the effect of clinical treatments on diaphragm function. However the reproducibility of Tw Pdi on different occasions has been little studied. We investigated 32 normal subjects, measuring Tw Pdi elicited by bilateral magnetic stimulation of the phrenic nerves on two to 14 occasions. Sniff transdiaphragmatic pressure (sniff Pdi) was also measured. The mean value of Tw Pdi and sniff Pdi were 28+/-5 and 134+/-24 cm H(2)O, respectively. The within subjects coefficient of variation was 11% for both Tw Pdi and sniff Pdi. We conclude that there is a variability of Tw Pdi and the variability of Tw Pdi is the same as that of sniff Pdi.

Diaphragm↗

Effect of medroxyprogesterone on inspiratory flow shapes during sleep in postmenopausal women.

We previously showed that medroxyprogesterone acetate (MPA) effectively decreases the arterial CO(2) levels in postmenopausal women with partial upper airway obstruction. The aim of the present study was to analyze the effects of MPA on the inspiratory flow shapes during sleep. Eight postmenopausal women with hypoxemia and partial upper airway obstruction during sleep (patients) received MPA 60 mg daily for 14 days. Four matched postmenopausal women without MPA treatment served as controls. Sleep and nasal pressure were recorded on each visit. Each breath was analyzed for duration, volume and inspiratory flow shape class. MPA shortened inspiration and prolonged expiration. The inspiratory volumes increased consistently in all flow shape classes. The inspiratory shapes with single late peak were transformed to those with double peak. MPA also decreased shapes with mid-peak or mid-plateau. MPA did not have an effect on sleep. Sleep modified the flow shape distribution only in patients but in a similar fashion in stages S2, SWS and REM. The results suggest that postmenopausal women present with a significant proportion breaths with poor initial inspiratory flow, which is reversed with MPA-induced respiratory stimulation.

Female↗

[Respiratory function monitoring: curves of pressure, volume and flow].

Respiratory function curves are a graphic representation of changes in volume, pressure or flow during the respiratory cycle. These changes can represent changes with respect to time (curves of volume-time, pressure-time and flow-time) or changes in one variable with respect to another (curves of flow-volume and of volume-pressure). Respiratory function curves enable analysis of the physiopathology in a patient, detection of changes in clinical status, optimization of ventilatory strategy, and evaluation of treatment response. They can also be used to facilitate patient comfort, prevent complications and iatrogeny, evaluate the course of weaning from mechanical ventilation, and help to establish a prognosis. In clinical practice these curves can show the presence of air leaks, indicate possible high resistance in the airway, suggest the possibility of trapped air, detect the presence of anomalous expiratory volume, identify the presence of secretions in the airway or water in the circuit, indicate the optimal PEEP, and reveal changes in pulmonary compliance.

Child↗