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PubMed2004

Manubriotomy versus median sternotomy in thymectomy for myasthenia gravis. Evaluation of the pulmonary status.

OBJECTIVE: In a prospective study, the effect of thymectomy on the pulmonary status of 50 consecutive patients with myasthenia gravis was evaluated over a time range of 4 years in the Chest and Chest surgery departments in the Cairo University Clinics and Thoracic Surgery Department of the Evangelisches Krankenhaus Duisburg-Nord. METHODS: The patients were divided into two groups: Group I included 26 patients who underwent thymectomy through median sternotomy. The mean age of the patients in this group was 24.8+/-10.5 (5-41) years. They were 19 females and seven males. Thirteen of the patients were in Myasthenia Gravis Foundation of America (MGFA) class IIa, and 12 were in class IIb, and one was in class IIIa. Group II included 24 patients who underwent thymectomy through manubriotomy. The mean age of the patients in this group was 25.2+/-9.2 (12-41) years. They were 13 females and 11 males. Eight of the patients were in MGFA class 2a, 14 were in class IIb, and two were in class IIIa. RESULTS: When compared to group I in which postoperative ventilation was required in 15.4% of patients, postoperative ventilation was not necessary in patients of group II with a statistically significant difference (P=0.04). The mean duration of stay in the intensive care unit was 111.4h in group II, and 169.7h in group I (P=0.03). The peak inspiratory flow rate and the forced vital capacity were also statistically significantly better in group II. There was no mortality in both groups, and the morbidity was higher in the median sternotomy group. CONCLUSION: Thymectomy through a manubriotomy, which allows extensive removal of ectopic thymic tissue in addition to the thymus through a less invasive approach than a full median sternotomy, is associated with a significantly smoother postoperative course and less pulmonary complications, when compared with thymectomy through a full median sternotomy.

Adolescent↗
PubMed1994

Severe asthma complicated by bilateral diaphragmatic paralysis attributed to Parsonage-Turner syndrome.

Progressive dyspnea that developed in a 52-year-old woman with a lifelong history of asthma did not respond to high-dose orally administered glucocorticoids. Initially, a diagnosis of allergic bronchopulmonary aspergillosis or hypersensitivity pneumonia was suggested as the cause of the worsening dyspnea. Pulmonary function tests demonstrated severe airway obstruction; substantial improvement was noted after bronchodilator therapy. Maximal inspiratory pressure was decreased, and the diffusing capacity of the lungs was abnormal. Computed tomography of the chest showed no parenchymal or mediastinal abnormalities. During a sniff test, fluoroscopy of her diaphragm disclosed paradoxical motion of both hemidiaphragms during inspiration, consistent with bilateral hemidiaphragmatic paralysis. Parsonage-Turner syndrome was diagnosed. The dose of glucocorticoids was tapered. Follow-up of the patient by telephone contact in March 1994 (9 months after her initial examination at our clinic) revealed that the dyspnea was still severe.

Asthma↗
PubMed1999

Celsior solution for improvement of currently used clinical standards of lung preservation in an ex vivo rat model.

OBJECTIVE: The introduction of Euro-Collins solution with its intracellular electrolyte composition has allowed for clinically accepted pulmonary preservation for up to 7 h of ischemic time. In recent years several alternative solutions have been developed for the improvement of pulmonary preservation. Celsior is an extracellular solution which has significantly reduced the ischemia/reperfusion (IR)-induced pulmonary damage in animal studies. So far, no larger experimental studies exist concerning the influence of Celsior on pulmonary gas exchange following IR. METHODS: In an extracorporeal rat lung model ten lungs, were each preserved with Celsior (CE) and Celsior/ prostacycline (CEPC, 6 mg/100 ml) at 4 degrees C and compared with preservation with low-potassium-Euro-Collins solution (LPEC, 40 mmol/l of potassium). After 2 h of ischemia the lungs were re-ventilated and reperfused using a roller-pump. Relative oxygenation capacity (ROC), pulmonary vascular resistance (PVR), peak inspiratory pressure (PIP) and wet/dry ratio were monitored for 50 min. Statistical analysis was performed using ANOVA. RESULTS: ROC was increased in all Celsior preserved organs compared with the EC group (P < 0.032). Though the CEPC group was found to have the lowest PIP and the least amount of lung water as assessed by wet/dry ratio, PVR was highest after 30-50 min. The significantly lowest PVR was determined in the CE group (P < 0.02). CONCLUSIONS: Celsior provides better lung preservation than LPEC solution, as demonstrated by a significantly increased oxygenation ability, a lower PVR and a decreased wet/ dry ratio. In vivo experiments and additional histological analysis are warranted for further evaluation of Celsior in lung preservation.

Analysis of Variance↗
PubMed1987

Effects of laser treatment on respiratory function in malignant narrowing of the central airways.

Twenty patients with inoperable carcinoma in the trachea or a main bronchus were investigated before and one and 10 days after treatment with a carbon dioxide laser. Patients were assessed by spirometry, maximum flow-volume loops, and a visual analogue score of breathlessness on a scale from 0 (not at all breathless) to 100 (very breathless). At day 10 mean FEV1 had improved from 51.9% to 62.6% of predicted (p less than 0.02) and mean peak expiratory flow (PEF) from 45.3% to 53.1% of the predicted value (p less than 0.05). Improvements in maximum inspiratory and expiratory flows at 50% vital capacity were not significant but the breathlessness score decreased from a mean of 49.1 to 35.3 (p less than 0.01). Improvements in breathlessness were significantly correlated with increases in FEV1 and PEF. Thirteen of the 20 patients had unilateral tumours with partial or complete occlusion of the main bronchus; in these perfusion and ventilation were assessed by radioisotope scans before and 10 days after treatment. Seven of the 13 patients showed an increase in perfusion of the affected lung after treatment but the improvement was small, with a mean increase in unilateral perfusion in the 13 patients of 2.4% of the total counts. Four patients with no perfusion of the affected side showed no significant improvement after laser treatment. Changes in ventilation scans were similar to those in perfusion. It is concluded that laser treatment improves airway function and dyspnoea in malignant narrowing of central airways and that in unilateral obstruction such treatment results, at best, in a small increase in the contribution of the affected lung to perfusion.

Aged↗
PubMed1983

Pulmonary mechanics during the ventilatory response to hypoxemia in the newborn monkey.

Dynamic lung compliance (CL), inspiratory pulmonary resistance (RL), and functional residual capacity (FRC) were measured in 10 unanesthetized 48 h-old newborn monkeys and seven 21-day-old infant monkeys during acute exposures to an equivalent level of hypoxemia. End-expiratory airway occlusions were performed and the pressure developed by 200 ms (P0.2) was utilized as an index of central respiratory drive. P0.2 demonstrated a sustained increase throughout the period of hypoxemia on day 2 despite the fact that minute ventilation (VI) initially increased but then fell back to base-line levels. Dynamic lung compliance fell and FRC increased by 5 min of hypoxemia in the newborns. The 21-day-old monkeys exhibited a sustained increase in both VI and P0.2 throughout the hypoxic period with no change in CL and FRC. RL did not change at either postnatal age during hypoxemia. These data indicate that the neonatal monkey is subject to changes in pulmonary mechanics (decreased CL and increased FRC) during hypoxemia and that these changes are eliminated with maturation.

Airway Resistance↗
PubMed1985

Enhancement of particle deposition by flow-limiting segments in humans.

Severe chronic obstructive pulmonary disease is associated with central deposition of inhaled aerosols. This pattern may be due to functional narrowing of the large airways during expiration at flow-limiting segments (FLS). Using a gamma camera and 2.5-micron particles, we compared the pattern of aerosol deposition following quiet breathing with that after a controlled forced expiration (cough) when FLS are known to form in central airways. Lung size measurement by 133Xe allowed construction of regions of interest over the central airways and lung periphery. Deposition in these regions was normalized for area and lung thickness and expressed as a central-to-peripheral (C/P) ratio. In addition, using right-angle light scattering, the fraction of inhaled particles deposited with each breath (DF) was determined. During control studies, airflow and tidal volume were continuously monitored to insure that tidal loops were well below the maximum expiratory flow-volume (MEFV) curve. To create dynamic compression, cough was used to generate a partial MEFV curve, while inspiratory flow, tidal volume, and functional residual capacity were maintained close to quiet breathing. With cough, C/P ratios increased markedly from 1.04 +/- 0.18 to 2.21 +/- 0.61 (P less than 0.01, n = 6). DF for the lung and airways did not significantly change (0.43 +/- 0.11 to 0.45 +/- 0.09, P = NS). The greater enhancement of regional deposition in the central airways with deposition unchanged over the whole lung demonstrates that, during cough, peripheral deposition is actually reduced when compared with quiet breathing. We conclude that dynamic compression at FLS can be an important factor in the central deposition of inhaled particles.

Humans↗
PubMed1992

Effect of chronic respiratory load on cytochrome oxidase activity in diaphragmatic fibers.

To determine whether the increase in oxidative capacity after respiratory muscle training with chronic inspiratory loads in sheep is specific to a particular fiber type, we measured cytochrome c oxidase (COX) activity in type I and type II fibers. COX activity in individual fibers was examined histochemically and measured as relative optical density by use of an image processing system. Fiber types were differentiated by the myosin adenosine-triphosphatase reaction. We found that COX activity was higher in both fiber types in the trained diaphragms than in the control diaphragms (P less than 0.01). The increase with training was greater in type II (39%) than in type I fibers (21%), resulting in relatively homogeneous COX activity in all diaphragmatic fibers. The proportion of type I fibers increased from 43.4 +/- 5.4% in the control diaphragm to 53.1 +/- 2.9% in the trained diaphragm, whereas the proportion of type II fibers decreased (P less than 0.001). We conclude that respiratory muscle training activates oxidative enzyme activity in both diaphragmatic fiber types; this activation is differentially more in type II fibers, which also decrease in proportion, and less in type I fibers, which increase in proportion.

Airway Resistance↗
PubMed1997

Contractions of specific abdominal muscles in postural tasks are affected by respiratory maneuvers.

The influence of respiratory activity of the abdominal muscles on their reaction time in a postural task was evaluated. The electromyographic (EMG) onsets of the abdominal muscles and deltoid were evaluated in response to shoulder flexion initiated by a visual stimulus occurring at random throughout the respiratory cycle. Increased activity of the abdominal muscles was produced by inspiratory loading, forced expiration below functional residual capacity, and a static glottis-closed expulsive maneuver. During quiet breathing, the latency between activation of the abdominal muscles and deltoid was not influenced by the respiratory cycle. When respiratory activity of the abdominal muscles increased, the EMG onset of transversus abdominis and internal oblique, relative to deltoid, was significantly earlier for movements beginning in expiration, compared with inspiration [by 97-107 ms (P < 0.01) and 64-90 ms (P < 0.01), respectively]. However, the onset of transversus abdominis EMG was delayed by 31-54 ms (P < 0.01) when movement was performed during a static expulsive effort, compared with quiet respiration. Thus changes occur in early anticipatory contraction of transversus abdominis during respiratory tasks but they cannot be explained simply by existing activation of the motoneuron pool.

Abdominal Muscles↗
PubMed2001

Increased frequency dependence of specific airway resistance in patients with laryngeal hemiplegia.

The aim of this study was to investigate whether patients with laryngeal hemiplegia (LH) show a frequency-dependent increase in specific airway resistance (sRaw), measured by body plethysmography. In addition to the flow-volume loop, usually considered in the functional evaluation of upper airway obstructions, variations in sRaw at respiratory frequencies of 30+/-5 (=0.5 Hz), 60+/-5 (=1 Hz) and 90+5 breaths x min(-1) (=1.5 Hz) in 21 never-smoking patients (LH group, mean age+/-SD 55+/-12.09 yrs; 17 females) whose unilateral vocal-cord paralysis was documented by laryngoscopy and who had no signs or symptoms of other respiratory diseases studied. They were compared to 21 healthy control subjects (C group: 50.1+/-15.44 yrs; 10 females). The sRaw values at 30+/-5 breaths min(-1) were similar in the two groups (5.54+/-1.88 versus 5.68+/-1.06 cmH2O x s(-1); p=NS), but at increasing frequencies (30+/-5, 60+/-5 and 90+/-5 breaths min(-1)), they progressively and significantly increased in the LH patients (from 5.54+/-1.88 to 6.63+/-1.96 and 8.05+/-2.6 mH2O x s(-1); p<0.0005), and not significantly in controls (5.68+/-1.06, 5.85+/-0.95 and 5.9+/-1.12 cmH2O x s(-1); p=NS). Linear discriminant analysis using AsRaw (sRaw at 1.5 Hz-sRaw at 0.5 Hz) and forced inspiratory flow at 50% of the vital capacity made it possible to correctly classify all of the controls and 19 of the 21 patients. In conclusion, the multiple, rapid and noninvasive plethysmographical testing of frequency-dependent increase in specific airway resistance with the flow-volume loop, allows the sufficiently satisfactory discrimination of laryngeal hemiplegia patients from controls.

Adult↗
PubMed2001

Respiratory function vs sleep-disordered breathing as predictors of QOL in ALS.

BACKGROUND: Most patients with ALS have evidence of respiratory muscle weakness at diagnosis, and death is usually due to respiratory failure. Sleep disruption, possibly due to apneas, hypopneas, orthopnea, or REM-related desaturation, is common. The relative impact of these factors on quality of life has not been established. METHODS: The authors recruited 23 subjects with probable or definite ALS. Quality of life was assessed using generic and specific instruments, and respiratory muscle strength by measurement of vital capacity, maximum static pressures, and sniff nasal inspiratory pressure. Twenty-two subjects underwent polysomnography. Overall limb and axial muscle strength was estimated using a summated muscle score based on the Medical Research Council clinical scale. RESULTS: On univariate analysis, there were moderate to strong correlations between quality of life and all measurements of respiratory muscle function (R = 0.42-0.82). The correlations with selected polysomnographic indices were weaker and less consistent (R = 0.44-0.59). Multivariate analysis showed that maximum static inspiratory pressure was the strongest independent predictor of quality of life. CONCLUSION: Quality of life was strongly and independently related to respiratory muscle function. Relations with polysomnographic indices were weaker and were attributable to respiratory muscle weakness. Respiratory muscle weakness is much more important than the frequency of apneas and hypopneas in determining quality of life in ALS.

Adult↗
PubMed2001

[Effect of inhaled anticholinergic drug on pulmonary function and quality of life in elderly patients with chronic obstructive pulmonary disease].

Effects of inhaled anticholinergic drug on the physiological function of the respiratory system and quality of life (QOL) in elderly patients with chronic obstructive pulmonary disease (COPD) have not been fully elucidated. We examined the pulmonary function, static respiratory pressures, and ventilation during exercise, before and after inhalation of oxitropium bromide (OTB) in 12 male patients with COPD (mean age 82.1 +/- 0.6 years). QOL was measured with a St George's Respiratory Questionnaire (SGRQ) in the patients. Forced expiratory volume in one second was increased by the inhalation of OTB in the patients, whereas the ratio of residual volume to total lung capacity was decreased by the inhalation. Maximum inspiratory pressure was significantly increased after the administration of OTB. Dyspnea sensation during exercise measured on the Borg scale was reduced by the inhalation of OTB. The scores of SGRQ were improved by one-month treatment with OTB. These results suggest that the treatment with OTB are effective for both physiological function and several aspects of QOL in elderly patients with COPD.

Administration, Inhalation↗
PubMed2002

[Effect of an inhaled beta 2-adrenergic agent on pulmonary function and quality of life in elderly patients with chronic obstructive pulmonary disease].

We tested the effects of inhaled beta 2-adrenergic drug on the physiologic function of the respiratory system and quality of life (QOL) in elderly patients with chronic obstructive pulmonary disease (COPD). We measured the pulmonary function, static respiratory pressures, and ventilation during exercise, before and after inhalation of the beta 2-adrenergic drug, fenoterol bromide (FB) in 12 male COPD patients (mean age 82.1 +/- 0.6 years old), QOL was measured with a St George's Respiratory Questionnaire (SGRQ) in the patients. Forced expiratory volume in one second was increased by the inhalation of FB in the patients, whereas the ratio of residual volume to total lung capacity was decreased by the inhalation. Maximum inspiratory pressure was significantly increased after the inhalation of FB. Dyspnea sensation during exercise assessed by the Borg scale was reduced by the inhalation of FB. The scores on SGRQ were improved by one-month treatment with FB. These results indicate that treatment with FB is effective for both physiological function of the respiratory system and several aspects of QOL in elderly patients with COPD.

Administration, Inhalation↗
PubMed2001

[Unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia].

We experienced a rare case of unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia. A 75-year-old man with a 1-pack a day smoking history for 50 years was scheduled for right upper and middle lobectomy for lung cancer. The trachea and left bronchus were intubated with a 37-Fr double-lumen endobronchial tube, and anesthesia was maintained with oxygen, nitrous oxide, isoflurane, and epidural lidocaine. Left single-lung ventilation was maintained for 3.5 hours with FIO2 at 0.8-1.0, vital capacity at 10 ml.kg-1, and peak inspiratory pressure at 25 cmH2O. On postoperative day 55, reticular nodular density in chest roentogenography appeared only in the left lung while right lung showed pleural fluid and pneumonia. On postoperative day 105, a high-resolution computed tomographic scan revealed honeycomb pattern in the left lung and organized pneumonia in the right lung. The patient died from respiratory failure on postoperative day 155, and autopsy was not performed. Although the causative mechanisms of unilateral pulmonary fibrosis in this case was unclear, the patient had not been exposed to any drugs and inhalation agents known to induce pulmonary fibrosis. We speculate that high oxygen concentration, high peak inspiratory pressure, and overdistension of the left lung during the left single-lung ventilation and anesthesia were likely major initiating and contributing factors.

Aged↗
PubMed2002

[Upper airway obstruction in thyroid diseases].

INTRODUCTION: Respiratory symptoms (stridor) in thyroid diseases are rather common, but often overlooked, especially in older people in whom they may be misinterpreted as asthma or chronic bronchitis. MATERIAL AND METHODS: To assess the value of lung function tests for differential diagnosis we used these tests in 33 patients with upper airway obstruction caused by an enlargement of the thyroid gland. The clinical examination consisted of an evaluation of the respiration, examination of the movement of the vocal chords, thyroid parameters, Tc scintigraphy, ultrasound examination, and X-ray examination of the thorax and trachea up to the level of the glottis, supplemented by a CT scan if needed. Lung function tests were carried out in all patients before and after the operation as conventional spirometry with registration of the flow-volume curve and application of peak expiratory flow (PEF), maximal expiratory and inspiratory flow at 50% of the vital capacity (MEF 50 and MIF 50) and MEF 50/MIF 50. RESULTS: The surgical treatment consisted in hemithyroidectomy in 10 patients and total thyroidectomy in 23 patients. In all cases, considerable clinical improvement in respiration was achieved and the X-ray examination showed a normalisation of the lumen of the trachea. In 24 of 33 patients (73%), the flow-volume curve showed preoperatively a configuration compatible with a variable upper airway obstruction (i.e. MIF 50 < MEF 50). An increase postoperatively was found in the PEF of 21 patients (64%) and MEF 50/MIF 50 < 1 in 19 patients (58%). DISCUSSION: It is important to distinguish between respiratory symptoms (stridor) caused by obstruction of the upper air way and dyspnoea in cardiopulmonary diseases. Lung function tests with registration of the flow-volume curve and measurement of MEF, MIF, and PEF are a useful supplement, as values indicating upper airway obstruction will be present in about 60% of the cases. Lung function tests pre- and postoperatively will serve as a good control on the effect of the operation on the thyroid gland.

Adult↗
PubMed1990

[Disorders of neuromuscular function and respiration].

Neuromuscular disorders of varying aetiology frequently lead to respiratory failure. This situation contrasts with the rare application of suitable tests of pulmonary function in this group of patients. As a result, respiratory complications are not detected until they have progressed to a terminal stage. With the sequential measurement of vital capacity, and a determination of the maximum inspiratory and expiratory pressures (PImax and PEmax), we have reliable and practicable diagnostic measures available that permit the recognition of respiratory failure at an early stage. This fact is of particular importance, since the application of modern ventilation techniques in suitable patients can make a substantial contribution towards both improving the patient's quality of life and prolonging it.

Diaphragm↗
PubMed1978

Recovery of communicative functions after prolonged traumatic coma.

Fifteen patients with prolonged coma after craniocerebral injury were observed for a year or more, and their communicative functions were evaluated. Nine of them showed a considerable degree of recovery, while 6 remained in a vegative state. Of the 9 with recovery, 6 showed complete recovery of semantic functions, while 3 remained with aphasic deficits. Eight out of these 9 remained dysarthric. Communicative recovery began as late as 5.7 months after injury, and it roughly paralleled recovery in locomotion and A.D.L. Restlessness and sweating were favorable prognostic factors. Excessive salivation, snout reflex, corneomandibular reflex, retractory nystagmus and stereotypic movements were unfavorable. The 8 patients who remained dysarthric showed marked diminution of their expiratory and inspiratory reserves, and of their forced vital capacity.

Adult↗
PubMed1997

Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy?

OBJECTIVES: The purpose of our study was to validate the incentive spirometry (IS) as a simple mean to follow pulmonary function at the bedside after lung surgery. MATERIALS AND METHODS: We studied prospectively 19 patients (16 men, 3 women; mean +/- SE age, 60 +/- 2.8 years) undergoing lobectomy for lung cancer. All the patients had an obstructive pattern with FEV1/FVC below 75%. Lung volumes, including functional residual capacity (FRC) and residual volume (RV), measured using spirometry and the helium dilution technique, and IS were measured preoperatively and postoperatively at days 1, 2, 3, and 8, and at 2 months. RESULTS: Our results showed that in the postoperative period after lung resection, IS performance was well correlated (R) during the first 8 postoperative days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and FRC (R below 0.470). CONCLUSIONS: IS can be used as a simple mean to follow lung function, especially VC and IRV, in the postoperative period in spontaneously breathing patients. IS is noninvasive and can be performed repeatedly at the bedside in the intensive care setting.

Expiratory Reserve Volume↗
PubMed1990

Target-flow inspiratory muscle training at home and during pulmonary rehabilitation in COPD patients with a ventilatory limitation during exercise.

The effects of a 10-week inspiratory muscle training (IMT) program at home were compared to IMT during a 10-week pulmonary rehabilitation program (PR) in 40 COPD patients with a ventilatory limitation of the exercise capacity. IMT was performed with a target-flow resistive device; the generated mouth pressure as well as the duty cycle were imposed. The mean age of the patients was 59, the mean FEV1 was 48% of predicted. In the training period the inspiratory muscle strength improved in both groups to the same degree. EMG fatigability of the diaphragm improved in the PR+ IMT group, but not in the IMT group. In the IMT group, the 12-min walking distance increased after the training period, but maximal workload (Wmax), VO2,max, and ADL scores did not change. In the PR + IMT group, however, Wmax, VO2,max, walking distance, and ADL scores improved significantly after the training period. Walking distance and ADL scores showed a significantly greater improvement in the PR + IMT group than in the IMT group. It is concluded that both isolated IMT and PR + IMT in COPD patients with a ventilatory limitation have a beneficial effect on inspiratory muscle strength, but PR + IMT improves the physical exercise capacity significantly more than IMT alone.

Activities of Daily Living↗