Short-term smoking reduction is associated with reduction in measures of lower respiratory tract inflammation in heavy smokers

The beneficial effect of short-term smoking reduction in reducing lower respiratory tract inflammation was assessed in 15 healthy heavy smokers. All underwent fibreoptic bronchoscopy and bronchoalveolar lavage and were then treated with at least 20 mg of nicotine gum daily. Self-reported cigarette consumption decreased from 50.7 +/- 2.3 to 18.8 +/- 1.5 (p less than 0.001) cigarettes daily, and expired CO decreased from 48.5 +/- 2.5 to 27.3 +/- 2.5 ppm (p less than 0.001). After two months, repeat bronchoscopy and bronchoalveolar lavage revealed that bronchial inflammation, as assessed by direct inspection, neutrophilia of bronchial lavage fluid, and the number of alveolar macrophages, the number of alveolar neutrophils and the concentration of neutrophil elastase alpha 1-antiprotease complex in alveolar lavage fluid, had improved significantly. The present study suggests that smoking reduction may be associated with an improvement in lower respiratory tract inflammation in heavy smokers and may, if persistent, be an alternative for smokers who cannot, or do not wish, to quit.

Evaluation of elastase and antielastase balance in patients with chronic bronchitis and pulmonary emphysema

On the basis of the "protease-antiprotease imbalance" theory for the pathogenesis of pulmonary emphysema, we hypothesized that measurement of elastase burden and antielastase capacity in the alveolar space might correlate with emphysema. To evaluate this, the severity of emphysema, the elastase burden, and the elastase inhibitory capacity were estimated in 28 patients with chronic bronchitis and variable degrees of emphysema, none of whom had congenital deficiency of alpha-1-protease inhibitor, and all of whom underwent bronchoalveolar lavage. Emphysema was assessed by both computed tomography and diffusing capacity. To examine "elastase burden," elastase:alpha-1-protease inhibitor complex and free elastase activity in alveolar lavage fluids were measured. To evaluate "antielastase" capacity, elastase inhibiting capacity in alveolar lavage fluid was measured. Elastase burden correlated directly and antielastase capacity correlated inversely with emphysema. These data provide direct support for the "protease-antiprotease imbalance" theory of emphysema in a group of smokers without congenital deficiency of alpha-1-protease inhibitor.

Short-term smoking reduction is associated with reduction in measures of lower respiratory tract inflammation in heavy smokers

The beneficial effect of short-term smoking reduction in reducing lower respiratory tract inflammation was assessed in 15 healthy heavy smokers. All underwent fibreoptic bronchoscopy and bronchoalveolar lavage and were then treated with at least 20 mg of nicotine gum daily. Self-reported cigarette consumption decreased from 50.7 +/- 2.3 to 18.8 +/- 1.5 (p less than 0.001) cigarettes daily, and expired CO decreased from 48.5 +/- 2.5 to 27.3 +/- 2.5 ppm (p less than 0.001). After two months, repeat bronchoscopy and bronchoalveolar lavage revealed that bronchial inflammation, as assessed by direct inspection, neutrophilia of bronchial lavage fluid, and the number of alveolar macrophages, the number of alveolar neutrophils and the concentration of neutrophil elastase alpha 1-antiprotease complex in alveolar lavage fluid, had improved significantly. The present study suggests that smoking reduction may be associated with an improvement in lower respiratory tract inflammation in heavy smokers and may, if persistent, be an alternative for smokers who cannot, or do not wish, to quit.

Bronchial epithelial cells respond to insulin and insulin-like growth factor-I as a chemoattractant

Migration of epithelial cells to cover areas of injury is thought to be important in the repair process following airway insult. Insulin is reported to be a growth factor for bronchial epithelial cells, and growth factors have been known to be chemotactic for many types of cells. Thus, we hypothesized that insulin may be a chemoattractant for bronchial epithelial cells. To evaluate this, we prepared bronchial epithelial cells and measured their chemotactic activity toward insulin. Bronchial epithelial cells were isolated by overnight digestion with bacterial protease, filtered through 100-microns nitex mesh, and then cultured at 1 x 10(6) cells/ml in tissue culture dishes in medium 199 supplemented with transferrin, insulin, epidermal growth factor, hydrocortisone, antibiotics, and 10% FCS for 3 d. The cultured cells were rinsed twice to remove supplements, trypsinized and resuspended at 1 x 10(6) cells/ml in medium 199 without supplements, and used as the cell source for chemotaxis. Chemotactic activity of bronchial epithelial cells was measured by the blindwell chamber technique using 8-microns Nuclepore filter membranes coated with 0.1% gelatin. The cells were added to the top wells in a 48-multiwell chamber with insulin in the bottom wells and incubated for 6 h at 37 degrees C, 5% CO2. Bronchial epithelial cells migrated in response to insulin in a dose-dependent manner up to an optimal dose of insulin, 100 micrograms/ml, and decreased at higher concentrations. The number of migrated cells per 10 high power fields was 33.7 +/- 1.9 at the optimum and 3.7 +/- 0.7 without insulin (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Bronchoalveolar lavage in the diagnosis of cancer]

Bronchoalveolar lavage (BAL) is a widely used clinical procedure. To determine if BAL could provide useful information in the detection of cancer, 850 lavages from 421 patients having BAL for a variety of indications, 50 lavages in patients with Hodgkin's disease and 20 patients with breast cancer undergoing bon marrow transplant were reviewed. BALs were performed with the technique established by Rennard and coll. in which 5 successive 20 cc aliquots are infused in a wedge position. The return from the first aliquot was processed separately from the subsequent four aliquots. Diff-Quick stained cytocentrifuge preparations and Papanicolaou stained millipore filter preparations were analyzed. Thirty-five patients had biopsy-proven lung cancer. In 24 (68.6%) of these, BAL revealed cells diagnostic of malignancy. There were no false positives. Six out of 50 Hodgkin's disease patients had Reed Sternberg cells detected on BAL, and 7/20 breast cancer patients had malignant cells on BAL prior to chemotherapy. In summary, the routine performance of BAL, an easily performed and well-tolerated procedure, may prove to be useful in the routine assessment of patients for cancer.

Modulation of alveolar macrophage leukotriene B4 released by complement component C5

The release of neutrophil chemotactic activity by the guinea pig alveolar macrophage (AM) is dependent on the fifth component of complement (C5) on the cell surface. Because one potent chemotactic factor released by AMs is leukotriene B4 (LTB4), we hypothesized that cell surface C5 may modulate LTB4 release. To test this hypothesis, human AMs obtained by bronchoalveolar lavage from 12 subjects were cultured for 4 hours in the presence of anti-C5 Fab' antibodies with stimuli. The cultures were harvested and evaluated for LTB4 by radioimmunoassay. The LTB4 levels in supernatants obtained from AMs cultured in media alone were variable (447 +/- 63 pg/ml), but the levels were increased when AMs were cultured with the stimuli-opsonized zymosan, immune complexes, or lipopolysaccharide (233%, 49%, and 114% increase, respectively, compared with macrophages cultured in media alone, p less than 0.05). Culturing the AMs with anti-C5 Fab' antibodies inhibited the release of LTB4 induced by opsonized zymosan, immune complexes, or lipopolysaccharide (78%, 41%, and 82% inhibition, respectively, p less than 0.05). Consistent with these observations, anti-C5 Fab' antibodies also decreased the neutrophil chemotactic activity of culture supernatants obtained from AMs stimulated with the same stimuli (p less than 0.001). These data suggest that AM release of LTB4 may be C5-dependent.

Pulmonary macrophages can stimulate cell growth of bovine bronchial epithelial cells

Macrophages are thought to participate in tissue repair following injury by releasing growth factors into the local environment. To evaluate whether pulmonary macrophages can mediate airway epithelial repair, we attempted to determine if pulmonary macrophages can stimulate growth of bovine bronchial epithelial cells in vitro. Bronchial epithelial cells isolated by protease digestion of the bovine bronchi were plated into tissue culture dishes with and without macrophage-conditioned medium. Bronchial epithelial cells cultured with macrophage-conditioned medium showed a significantly greater cell growth than those without macrophage-conditioned medium when assessed by direct enumeration of the cell numbers and by clonal growth assay. Stimulation of proliferation was confirmed by autoradiography using [3H]thymidine uptake into cell nuclei. Co-culture of pulmonary macrophages with bronchial epithelial cells also led to an increase in cell number. Immunohistochemical staining of the proliferating cells showed that these cells were positively stained by anti-keratin antibodies confirming that they were bronchial epithelial cells. Partial characterization of the activity in macrophage-conditioned medium showed that it was nondialyzable, pepsin- and acid-labile, and lipid-inextractable. Sephadex G-75 column fractionation indicated this activity existed in a high molecular fraction, thus suggesting a peptide. DEAE ion exchange chromatography revealed 3 peaks of stimulating activity. One peak resulted in a decrease in cell number, suggesting a possible inhibitory activity. The DEAE results thus suggest that macrophages may release several factors that can affect bronchial epithelial cell proliferation. In conclusion, pulmonary macrophages stimulate cell proliferation of bronchial epithelial cells in vitro. The stimulatory activity that may be heterogeneous appears to have the properties of a peptide.

[The use of bronchoalveolar lavage (BAL) in the study of airway inflammation]

Bronchoscopy and bronchoalveolar lavage can be used to investigate the airways inflammation associated with chronic bronchitis. Visual inspection of the airways provides presumptive evidence of inflammation and bronchoalveolar lavage can recover samples enriched for airways epithelial lining fluid contents. The ability to sample airways inflammation may provide a means of characterizing the airways inflammation associated with chronic bronchitis and of identifying mediators of inflammation that perpetuate the inflammation. Furthermore, bronchoalveolar lavage in conjunction with pulmonary function testing may provide a means for rapidly assessing responses to new therapeutic interventions.

Smoking cessation in the workplace: evaluation of relapse factors

Relapse factors associated with a well-supported worksite smoking cessation program were examined in a prospective study. Of 104 employee-participants, 81 (78%) were confirmed as abstinent at 8 days after quit day. Forty-six employees (44%) continued to report total abstinence at 1 year. Stepwise regression analysis of baseline variables found two significant, but weak, predictors of 1-year smoking status: Fagerstrom score and number of other smokers residing in the home. Analysis of tobacco withdrawal symptom data of confirmed abstainers found only self-reported anxiety scores to be predictive of smoking status at 1 year. Early abstainers with elevated anxiety scores appear to be at high risk for smoking relapse.

Lung fibroblasts produce growth stimulatory activity for bronchial epithelial cells

Interaction between lung fibroblasts and airway epithelial cells may play an important role in lung morphogenesis and airway repair after injury. Even though many reports have suggested that mesenchymal fibroblasts have a growth stimulatory effect on surrounding epithelial cells, very few have attempted to confirm and characterize the growth stimulatory activity in isolated cell systems. We cultured human fetal lung (HFL-1) fibroblasts, harvested supernatant-conditioned media under serum-free conditions, and examined their growth stimulatory effect on bovine bronchial epithelial cells by a variety of techniques, including direct enumeration, thymidine uptake, and metaphase arrest. We also partially characterized the growth stimulatory activity and examined the effect of an inhibitor of DNA synthesis on its release. The results demonstrate that HLF-1 fibroblasts release growth stimulatory activity for bovine bronchial epithelial cells. This activity is nondialyzable, protease-sensitive, acid-stable, and lipid-inextractable and thus appears to have the property of protein; it may be produced by de novo synthesis. Molecular sieve chromatography on Sephadex G-75 indicates an approximate molecular mass of 6,000 D. This growth stimulatory activity is likely to play roles in lung morphogenesis and airway repair after injury.

Fractional processing of sequential bronchoalveolar lavage to separate bronchial and alveolar samples

Bronchoalveolar lavage has been widely used to sample the lower respiratory tract. Most of the material recovered with this technique represents alveolar contents. A number of modifications have been suggested in order to obtain samples relatively enriched for bronchial material. In order to be able to use a standard technique for bronchoalveolar lavage to sample both airways and "routine" alveolar material, a simple modification of the technique as described by Reynolds and Newball was used: five sequential 20-ml aliquots were infused into the lower respiratory tract, and each aliquot was immediately aspirated. The return from the first aliquot was processed separately from the return from the subsequent four aliquots. These last four aliquots were pooled. Analysis of the first aliquot revealed it to be enriched for ciliated epithelial cells when compared with the subsequent aliquots. There were also differences in inflammatory cell composition with the bronchial sample containing relatively more neutrophils and relatively less lymphocytes. Aspiration during transoral bronchoscopy was documented by quantifying salivary amylase in the bronchial and alveolar lavage fluids. It was estimated, however, that the aspiration was not of quantitative significance in the vast majority of subjects studied. Finally, with the technique of fractional processing of bronchoalveolar lavage samples, it was possible to compare the protein concentrations in bronchial and alveolar lavages. Most prominent among the differences was a marked relative enrichment in the bronchial samples for immunoglobulin A. The technique of fractional processing of bronchoalveolar lavage samples provides a simple means to obtain samples enriched for bronchial and alveolar components. This should facilitate analysis of lower respiratory tract specimens in airway disease.

Organic dust toxic syndrome: an acute febrile reaction to organic dust exposure distinct from hypersensitivity pneumonitis

Organic dust toxic syndrome is a term recently coined to describe a noninfectious, febrile illness associated with chills, malaise, myalgia, a dry cough, dyspnea, headache and nausea which occurs after heavy organic dust exposure. Organic dust toxic syndrome shares many clinical features with acute farmer's lung and other forms of hypersensitivity pneumonitis, including the presence of increased numbers of neutrophils in bronchoalveolar lavage. However, organic dust toxic syndrome differs from acute hypersensitivity pneumonitis in several respects: the chest X-ray does not show infiltrates, severe hypoxemia does not occur, prior sensitization to antigens in the organic dust is not required and there are no known sequelae of physiological significance, such as the recurrent attacks and the pulmonary fibrosis which may be seen with chronic hypersensitivity pneumonitis. Organic dust toxic syndrome is thought to be much more common than farmer's lung. It is important for clinical and investigational purposes that organic dust toxic syndrome be distinguished from acute farmer's lung.

Bronchial epithelial cells produce chemotactic activity for bronchial epithelial cells. Possible role for fibronectin in airway repair

Bronchial mucosal injury initiates a complex series of repair mechanisms, one of which is reepithelialization of a denuded lumenal surface. This suggests the hypothesis that bronchial epithelial cells, the cells initially affected by bronchial injury, might be able to initiate repair of an injured area by producing a chemotactic activity for intact bronchial epithelial cells. To evaluate this, bronchial epithelial cells were prepared from bovine lung by protease digestion and cultured in medium 199 (M199) with 10% fetal calf serum (FCS) until confluence, after which the cells were rinsed with Hanks' balanced salt solution, and serum-free fresh M199 was added. This conditioned medium was then collected and used to test the chemotactic response of bronchial epithelial cells using a blindwell chamber technique. Target cells for this assay were isolated from airways by protease digestion, grown to confluence in M199 with 10% FCS, and then harvested with trypsin. Bronchial epithelial cell-conditioned medium harvested after 3 days attracted more cells (197.0 +/- 5.7 cells/10 high power fields) than did M199 without FCS alone (4.3 +/- 0.9) (p less than 0.01). Checkerboard analysis showed that the migration was chemotactic. The chemotactic activity was nondialyzable, pepsin-labile, acid-stable, heat-labile, and lipid-inextractable. The chemotactic activity accumulated in the culture medium with time. The addition of 25 micrograms/ml of cycloheximide inhibited this accumulation. Column chromatography with Sephadex G-150 revealed a single peak of chemotactic activity in the high molecular weight range. The chemotactic activity was bound to gelatin-Sepharose 4B and was eluted with 6 M urea.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo and in vitro methods for evaluating airways inflammation: implications for respiratory toxicology

The lung is frequently the target of injury for toxic exposures. Often these exposures lead to significant disease. Assessment of toxic exposures to the lung, however, may be made using both in vitro and in vivo methods. Recent advances in respiratory cell biology have made possible in vitro analyses of the interactions between airway cells and potential toxins. In addition, the lung can be sampled in vivo using bronchoscopy and bronchoalveolar lavage. This opens up the possibility of assessing potential toxins prior to the development of clinically significant disease. Together, these advancing methodologies promise new potential for the assessment and evaluation of toxic exposures to the lung.

Intraluminal airway inflammation in chronic bronchitis. Characterization and correlation with clinical parameters

In order to characterize intraluminal airway inflammation in subjects with chronic bronchitis, bronchoscopy and bronchoalveolar lavage were performed in 28 subjects with chronic bronchitis with fixed airway obstruction and, for comparison, 15 asymptomatic smokers and 25 normal nonsmoking volunteers. The chronic bronchitics had a cough productive of sputum on most days of the month for 6 months in the preceding 2 yr, had at least one exacerbation requiring medical intervention in each of the previous 2 yr, and had an FEV1 less than 76% of predicted without response to bronchodilator. During bronchoscopy the airways were assessed for visual evidence of inflammation by assigning them a score, the bronchitis index, that graded the airways according to the apparent severity of airway edema, erythema, friability, and secretions. Bronchoalveolar lavage was performed by sequentially instilling and retrieving with gentle suction five 20-ml aliquots of sterile normal saline into each of three separate lobes. The first aliquots, the "bronchial" sample, were pooled and processed separately from the final four aliquots, the "distal" sample. Cell counts, cell differentials, and albumin were determined for both the bronchial and distal samples. In order to correlate inflammation with clinical parameters, sputum was collected for 24 h prior to bronchoscopy; spirometry was performed just prior to bronchoscopy, and smoking histories were obtained. Visual inspection of the airways, as quantified by the bronchitis index, demonstrated significantly more evidence for inflammation in the chronic bronchitics than in either the asymptomatic smokers or the normal subjects. The bronchial sample lavage fluids from the chronic bronchitics tended to contain more cells (6.1 +/- 2.2 x 10(6) cells) than the bronchial sample fluids from the asymptomatic smokers (3.6 +/- 0.6 x 10(6) cells) or normal subjects (3.7 +/- 0.5 x 10(6) cells). Furthermore, the chronic bronchitics had a higher percentage of neutrophils in their bronchial lavage fluid (35.8 +/- 5.6%) than did either the asymptomatic smokers (20.7 +/- 2.6%, p = 0.0001) or the normal subjects (10.3 +/- 5.6%). The distal sample lavage fluid also recovered more neutrophils from both the chronic bronchitics (15.0 +/- 4.2%, p = 0.0012) and asymptomatic smokers (5.7 +/- 1.3%, p = 0.002) than from the normal subjects (2.8 +/- 0.4%). The chronic bronchitics were divided into two groups: those with low (less than 20%) and those with high (greater than 20%) bronchial sample neutrophils. Those with higher bronchial sample neutrophils had significantly more sputum production and lower FEV1, FEV1/FVC, and FEF25-75 than did the subjects with lower bronchial sample neutrophils.(ABSTRACT TRUNCATED AT 400 WORDS)

Bronchial epithelial cells release chemoattractant activity for monocytes

Lung macrophages are monocyte-derived cells that play a central and essential part in local immunity. Because the bronchial epithelial cells that line the airway can modulate their local cellular environment by releasing chemotactic factors for neutrophils, lymphocytes, and fibroblasts, we postulated that the bronchial epithelial cells might release chemotactic activity for monocytes. To test this hypothesis, bovine bronchial epithelial cells were isolated and cultured. The supernatant fluids were collected at 12, 24, 36, 48, 72, 96, and 120 h and evaluated for monocyte chemotactic activity, using a blind-well chamber technique. The supernatant fluids possessed significantly greater chemotactic activity than medium alone, with optimal migration contained in supernatant fluids harvested at 72 h (5.8 +/- 2.3 vs. 39.8 +/- 2.8 cells/high-power field, P less than 0.001). Partial characterization of the released monocyte chemotactic activity revealed that the cells released a low-molecular-weight lipid-soluble chemotactic factor after 24 h in culture, but in contrast, a high-molecular-weight protein chemokinetic factor was released after 72 h in culture. These findings suggest that bronchial epithelial cells may release chemotactic activity for, and thus may modulate the recruitment of, monocytes into bronchial passages.

Bronchial epithelial cells release chemotactic activity for lymphocytes

Lymphocytes can frequently be observed in association with bronchial tissues. One mechanism that might account for this association is that bronchial epithelial cells might release chemotactic factors for lymphocytes. To test this hypothesis, bovine bronchial epithelial cells were cultured in serum-free media, and the supernatant fluids were harvested and evaluated for lymphocyte chemotactic activity using a blind-well chamber technique. Media alone attracted few lymphocytes (12 +/- 2 cells/high power field), but in contrast, there was a significant increase in the number of cells attracted by supernatant fluids obtained from bronchial epithelial cell cultures (40 +/- 6 cells/high power field, P = 0.002). The activity was dose dependent and was demonstrated to be chemotactic activity by checkerboard analysis. Partial characterization of the activity revealed it was not extractable into ethyl acetate but was partially inactivated by trypsin and heat (100 degrees C, 15 min). The responding cells were predominantly T-helper lymphocytes as shown by monoclonal antibody staining, with a smaller proportion being B-lymphocytes. Molecular sieve column chromatography revealed multiple peaks of lymphocyte chemotactic activity, with three of the peaks preferentially attracting T-helper lymphocytes and one of the peaks preferentially attracting B-lymphocytes. These data demonstrate that bronchial epithelial cells can release chemotactic factors for lymphocytes and suggest that bronchial epithelial cells may modulate their local population of immune effector cells.

Lung fibroblasts produce chemotactic factors for bronchial epithelial cells

The interaction between the epithelial cells and the subjacent mesenchymal cells in the airway is thought to play a major role during tissue repair and morphogenesis. To evaluate this interaction, we cultured human lung fibroblasts and bovine bronchial epithelial cells and determined that fibroblast-conditioned medium has chemotactic activity for bronchial epithelial cells. This activity was nondialyzable, heat labile, pepsin labile, acid stable, lipid inextractable, and eluted from Sephadex G-150 column chromatography in the high-molecular-weight range. DEAE-Sephacyl ion exchange and gelatin-Sepharose affinity chromatography revealed two peaks containing chemotactic activity, one of which may be fibronectin, since it binds to gelatin, reacts in a specific immunoassay, and is inhibited of chemotactic activity by anti-fibronectin antiserum, and another of which does not appear to be fibronectin, since it does not bind to gelatin nor react in the immunoassay. Thus lung fibroblasts can produce at least two chemotactic factors for bronchial epithelial cells that may play a role during lung tissue repair and morphogenesis by modulating bronchial epithelial cell migration.

Bronchoalveolar lavage in the assessment of pulmonary Hodgkin's disease

Abnormal chest radiographs in patients with Hodgkin's disease are occasionally due to pulmonary Hodgkin's disease. The fluids recovered from bronchoalveolar lavages (BALs) from 50 patients prior to autologous bone marrow transplantation for advanced Hodgkin's disease were examined. Abnormal chest roentgenograms were present in 24 patients (48%); 4 (17%) of these had Reed-Sternberg cells or their mononucleated variants in the lavage fluid and an alveolar lymphocytosis averaging 31.4% (normal: 11.5%). The lymphocytes were small and monotonous. Of the 20 patients with abnormal chest roentgenograms but no Reed-Sternberg cells in the lavage fluid, the lymphocyte count was 10.88%, with only 3 patients exceeding 17%. Two patients with normal chest roentgenograms had Reed-Sternberg-like cells in their lavage fluids and averaged 23% lymphocytes in their lavage differential count. Eosinophils averaged 1% or less of the lavage differential and were not predictive of pulmonary Hodgkin's disease. This experience suggests that pulmonary Hodgkin's disease can be diagnosed by BAL. Reed-Sternberg cells and their mononucleated variants can be recognized by their characteristic cytomorphologic features, although care must be taken not to misinterpret reactive binucleated macrophages as neoplastic cells. In patients with Hodgkin's disease, Reed-Sternberg cells should be sought when an alveolar lymphocytosis is present.

Bronchoalveolar lavage in liver transplant patients

Because immunosuppression is required to control rejection, liver allograft recipients are susceptible to a variety of opportunistic pathogens. A total of 191 bronchoalveolar lavage (BAL) specimens from 89 patients (53 adults and 36 children) who underwent orthotopic liver transplantation was reviewed. One case each of cytomegalovirus (CMV), staphylococcal and Enterobacter pneumonia was diagnosed with the aid of pretransplant BAL. The pretransplant BAL in 62 patients showed rare yeasts in 24.2%; these probably represent oropharyngeal contaminants since the patients involved had no symptoms of Candida pneumonia. Among 54 patients who developed respiratory symptoms and underwent posttransplant BAL, 23 (42.6%) were infected with opportunistic pathogens, including Pneumocystis carinii (22.2%), CMV (22.2%) and herpes simplex virus (HSV) (7.4%). Frequently, infection with multiple organisms was present. Adults constituted 100% of the HSV-infected group, 69.2% of the CMV-infected group and 16.6% of the group infected with P carinii. The diagnosis of these infections was aided by a combination of cytology, microbial culture and in situ hybridization techniques. Although BAL permitted the diagnosis and treatment of opportunistic infections, high mortality (62.5%) occurred with CMV and HSV pneumonia. Further studies into methods that permit earlier diagnoses of these infections are necessary.

Bronchial epithelial cells produce lung fibroblast chemotactic factor: fibronectin

The interaction between the epithelial cells and the subjacent mesenchymal cells in the airway is thought to play a major role during tissue repair after airway injury and lung morphogenesis. To evaluate this interaction, we cultured human lung fibroblasts, and bovine and human bronchial epithelial cells, and determined that bronchial epithelial cell-conditioned medium has a chemotactic activity for lung fibroblasts. This activity had the characteristics of protein: it was nondialyzable, heat-labile, pepsin-labile, acid-stable, and lipid-inextractable. Molecular sieve chromatography on Sephadex G-150 and affinity chromatography on gelatin-Sepharose revealed that there was one peak of chemotactic activity in high molecular weight range, which bound to gelatin, thus suggesting that the chemotactic factor might be fibronectin. Production and secretion of fibronectin into the culture media were demonstrated by biosynthetic incorporation of radioactive amino acid into fibronectin followed by immunoprecipitation on SDS-PAGE and autoradiography. Release into the culture medium was confirmed by ELISA. The identity of fibronectin as the chemotactic activity was confirmed by the addition of antifibronectin antibody to the conditioned medium, which inhibited chemotaxis in dose-dependent manner. Thus, bronchial epithelial cells produce fibronectin which can function as a chemotactic factor for lung fibroblasts. This production of fibronectin by bronchial epithelial cells may play an important role in regulating interaction between the bronchial epithelial cells that line the lumenal surface of the bronchial epithelial wall and the mesenchymal fibroblasts that underlie the bronchial epithelial basement membrane.

Bronchoalveolar lavage fluid processing. Effect of membrane filtration preparation on neutrophil recovery

Two common methods for the preparation of bronchoalveolar lavage (BAL) fluid for cytologic examination, cytocentrifugation and membrane filtration, have been found to yield different results in the quantitation of lymphocytes. To compare these two methods for the quantitation of neutrophils, the differential counts from 640 consecutive clinical specimens were analyzed retrospectively. The percentage of neutrophils resulting from the preparation of the BAL fluids by the two methods were highly correlated (r2 = .72). However, cytocentrifugation yielded consistently higher neutrophil percentages than did membrane filtration (means for all samples: 18.5 +/- 1.0% vs. 14.7 +/- 0.9%; P less than .001). To investigate the source of the variation in neutrophil quantitation by the two methods, two series of mixing experiments were performed in which neutrophil-rich cell suspensions were added to BAL fluids. Determination of the cellular differentials before and after mixing the cell suspensions demonstrated that membrane filtration preparation tends to lose neutrophils while cytocentrifugation accurately recovers neutrophils. Thus, accurate quantitation of the two cells recovered by BAL may require use of both cytocentrifugation and membrane filtration.

Neutrophil chemotactic factors in bacterial pneumonia

The influx of neutrophils into the lung is a prominent feature in patients with bacterial pneumonia. Since neutrophils migrate in response to chemotactic factors, chemotactic activity was evaluated in bronchoalveolar lavage (BAL) fluid obtained from 12 patients with bacterial pneumonia and ten normal control subjects. Chemotactic activity was greatly elevated in the BAL fluid of the pneumonia patients compared with control subjects (p less than 0.01). To partially characterize the chemotactic factors present in the lavage fluid of the patient group, molecular sieve chromatography was performed on the lavage fluid, and at least three peaks of chemotactic activity were identified. Since the molecular weight of the smaller peaks approximated the molecular weight of two known chemotactic factors, C5a and leukotriene B4, these factors were measured in lavage fluid by radioimmunoassay. C5a was detectable in none of the normal subjects but was detectable in four of 14 BAL samples obtained from the patients. Leukotriene B4 was detectable in all subjects and was significantly elevated in the pneumonia patients (552 +/- 95 vs 81 +/- 16 pg/ml, p less than 0.01). These findings demonstrate that elevated neutrophil chemotactic activity is present in the lungs of patients with bacterial pneumonia and suggest that C5a and leukotriene B4 may account, at least in part, for this increase.

Breast carcinoma in bronchoalveolar lavage. A cytologic and immunocytochemical study

To evaluate the effectiveness of bronchoalveolar lavage in detecting pulmonary metastases of breast cancer, we examined lavage fluid from 20 patients with routine cytologic preparations and immunoperoxidase stains with monoclonal antibody B72.3. Bronchoscopy was performed for infection surveillance prior to autologous bone marrow transplantation (nine patients), or to assess abnormal chest roentgenogram (11 patients). Metastatic adenocarcinoma was identified on Papanicolaou-stained-membrane filters in seven patients (35%), corroborated by transbronchial biopsy in four patients. No patients with chest roentgenogram suggestive of metastatic cancer or transbronchial biopsy positive for metastatic cancer had a negative lavage. Monoclonal antibody B72.3 uniformly marked malignant cell aggregates and many single cells that were inapparent in routinely stained material. Because bronchoalveolar lavage may detect metastatic adenocarcinoma with sensitivity comparable to transbronchial biopsy but with less morbidity, it is useful in the evaluation of pulmonary infiltrates in patients with primary breast carcinoma. Staining with monoclonal antibody B72.3 can be readily performed on lavage specimens and may serve as an adjunct in diagnosing malignancy.

Assessment of airways inflammation utilizing bronchoalveolar lavage

Pathologic correlations and examination of expectorated sputum have suggested that chronic bronchitis is an inflammatory disorder of the airways. Bronchoscopy and bronchoalveolar lavage provide a means for sampling airway epithelial lining fluid. Application of bronchoscopy and bronchoalveolar lavage to a group of patients with chronic bronchitis confirms the association of airways inflammation and chronic bronchitis.

Detection of Candida antigen in bronchoalveolar lavage fluid

While bronchoalveolar lavage is frequently performed to evaluate immunocompromised hosts for infection, the significance of rare yeasts found on the cytologic examination of lavage fluid is unclear. This study used the latex agglutination method to test lavage fluids for Candida antigen to assess its usefulness in distinguishing Candida pneumonia from Candida colonization of the respiratory tract or oral contamination of the lavage specimen. Ninety-seven specimens from 87 patients were categorized on the basis of historical, microbiologic, cytologic and serologic data. Bronchoalveolar lavage fluids were positive for Candida antigen in 0 of 20 specimens from normal controls, 0 of 14 specimens from patient controls, 5 (36%) of 14 specimens from patients with Pneumocystis carinii pneumonia, 0 of 5 specimens from patients with gastrointestinal candidiasis, 0 of 9 specimens contaminated by oral-derived yeasts, 2 (10%) of 19 specimens from patients with probable Candida colonization and 15 (94%) of 16 specimens from patients with clinical and laboratory evidence of Candida pneumonia. We conclude that this test assists in the differentiation of Candida pneumonia from other situations in which yeasts are recovered by bronchoalveolar lavage.

Colchicine suppresses the release of fibroblast growth factors from alveolar macrophages in vitro. The basis of a possible therapeutic approach ot the fibrotic disorders

Fibrosis is the accumulation of fibroblasts and the connective tissue products secreted by these cells, usually subsequent to tissue injury. While fibrosis can be useful in preserving the general structural integrity of a tissue, it often alters cell-cell and cell-connective tissue interactions, which leads to loss of tissue function. On the basis of the concept that mononuclear phagocytes can direct the development of fibrosis through the release of specific mediators that stimulate fibroblast proliferation, we propose a therapeutic strategy to prevent fibrosis by preventing the release of these specific mediators. The present study demonstrated that colchicine, a widely used and well-tolerated drug, can block alveolar macrophage release of 2 mediators associated with the development of fibrosis in interstitial lung diseases, fibronectin, and the alveolar-macrophage-derived growth factor (AMDGF). Colchicine blocked the spontaneous release of fibronectin by alveolar macrophages obtained from patients with fibrotic lung disease by 23 +/- 4% after 24 h and by greater than 90% after 72 h. AMDGF release was blocked by 68 +/- 10% after 4 h (p less than 0.01, all comparisons). The effect of colchicine was not due to nonspecific toxicity since [14C]proline tracer studies demonstrated that macrophages treated with colchicine were capable of de novo protein synthesis and the secretion of several protein products, despite the fact that fibronectin and AMDGF release were suppressed. The effect of colchicine on the spontaneous release of both fibronectin and AMDGF could be observed at concentrations less than 10 ng/ml, levels that can be achieved in vivo.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of the lower respiratory tract inflammation of nonsmoking individuals with interstitial lung disease associated with chronic inhalation of inorganic dusts

The pneumoconioses, interstitial lung disorders resulting from the inhalation of inorganic dusts, are associated with chronic inflammatory processes in the lower respiratory tract. To characterize these inflammatory processes in relation to the pathogenesis of these disorders, we studied 39 nonsmoking individuals with long-term occupational exposures to inorganic dust and functional evidence of interstitial disease (asbestosis, n = 18; coal workers' pneumoconiosis, n = 15; silicosis, n = 6). In all 3 disorders, the inflammation was dominated by alveolar macrophages. Because a common feature of these interstitial lung diseases is concurrent injury and fibrosis of alveolar walls, we assessed whether these alveolar macrophages were spontaneously releasing mediators capable of giving rise to these changes. Alveolar macrophages from the study population were spontaneously releasing increased amounts of superoxide anion and hydrogen peroxide (both p less than 0.01 compared to normals), oxidants capable of injuring lung parenchymal cells. The alveolar macrophages were also spontaneously releasing significantly increased amounts of fibronectin and alveolar macrophage-derived growth factor (both p less than 0.01 compared to normals), mediators that act synergistically to signal fibroblast replication. Taken together, these findings define a major role for the alveolar macrophage in mediating the alveolar wall injury and fibrosis that characterize the common pneumoconioses and suggest that the alveolar macrophage is an important "target" for developing strategies designed to prevent loss of lung function in these individuals.

Bronchoalveolar lavage in the cytologic diagnosis of carcinoma of the lung

To assess the utility of bronchoalveolar lavage as a technique for diagnosing lung cancer, 850 lavages from 421 patients were reviewed. Biopsy-proven lung carcinoma was present in 35 cases. Of these, 24 (68.6%) had cells diagnostic of malignancy on cytologic preparations of the bronchoalveolar lavage fluid. Agreement between cancer subtypes determined by lavage and by tissue biopsy was 79.1%; variation usually occurred between large cell undifferentiated carcinoma and adenocarcinoma, not with small cell anaplastic carcinoma. The subtype of tumors was most accurately determined by examination of Papanicolaou-stained slides. Reactive bronchial epithelium often mimicked carcinoma, but could be correctly identified by its characteristic cytomorphology. No false-positive diagnoses of lung cancer occurred in 386 patients. The sensitivity of bronchoalveolar lavage for the diagnosis of lung carcinoma is similar to that of transbronchial biopsy and Wang needle biopsy. Because bronchoalveolar lavage may detect opportunistic infections, interstitial lung diseases and malignant cells with a low morbidity, it is a useful tool to assess patients with pulmonary infiltrates.

Cytopathology of opportunistic infection in bronchoalveolar lavage

Bronchoalveolar lavage is an important tool for the cytologic and microbiologic examination of the lung. Silver- or Papanicolaou-stained slides from 604 lavage specimens from 344 patients were evaluated for the presence of fungal, parasitic, and viral organisms. Yeast, pseudohyphae, or hyphae occurred in 155 specimens (25.7%). Candida was the most frequent opportunistic fungus in immunosuppressed hosts. Patients with clinically significant Candida infection had many budding yeasts and pseudohyphae on cytologic preparations of their lavage fluid. Aspergillus, which occurred in five patients, was readily identified by cytologic examination and by fungal culture. Pneumocystis carinii was found in 14 patients (4%). Cytopathologic characteristics of Herpes simplex or cytomegalovirus were present in four patients (1.2%). In 414 specimens no pathogens were identified by either microbial culture or cytologic examination; usually, these patients had pulmonary hemorrhage, recurrent neoplasia, or therapy-induced lung disease to account for their abnormal chest x-rays. Cytologic and microbiologic examination of lavage fluid readily identified opportunistic pathogens. The ease and low morbidity of bronchoalveolar lavage support its use in the assessment of pulmonary infiltrates in immunocompromised hosts.

Elevation of chemotactic factor inactivator in alcoholic liver disease

Defective regulation of neutrophil chemotaxis occurs in patients with alcoholic liver disease. One potent mediator of neutrophil chemotaxis is the complement-derived neutrophil chemoattractant, C5a, which can be inhibited by a serum protein, chemotactic factor inactivator. We hypothesized that chemotactic factor inactivator elevation might, in part, explain the defective neutrophil chemotaxis seen in patients with alcoholic hepatitis. To test this hypothesis, sera were collected from 22 patients with alcoholic hepatitis and 9 normal controls, and evaluated for the antigenic presence of chemotactic factor inactivator using an ELISA test. Chemotactic factor inactivator levels were found to be markedly elevated in patients with alcoholic hepatitis (162 +/- 24 micrograms per ml) compared to normals (60 +/- 3 micrograms per ml, p less than 0.01). Subdividing the hepatitis patients revealed that the elevation of chemotactic factor inactivator was found to be greatest in those patients with mild alcoholic hepatitis (prothrombin time within normal limits and bilirubin less than or equal to 5 mg per dl, 256 +/- 44 micrograms per ml, p less than 0.001), while the group with the severest hepatic dysfunction (prolonged prothrombin time and bilirubin greater than 5 mg per dl) did not differ significantly from controls (71 +/- 11 micrograms/ml, p less than 0.2). Importantly, the inhibition of C5a-induced chemotactic activity by partially purified chemotactic factor inactivator correlated with antigenic amounts of chemotactic factor inactivator in serum (r = 0.63, p less than 0.05). The C5a inhibitory activity in sera obtained from patients with alcoholic hepatitis coprecipitated with chemotactic factor inactivator when serum was precipitated by ammonium sulfate precipitation (45 to 64% saturation).(ABSTRACT TRUNCATED AT 250 WORDS)

Cytomorphology of Alternaria in bronchoalveolar lavage specimens

Review of the bronchoalveolar lavage specimens from 326 patients resulted in the identification of Alternaria in 28 (8.6%) of the specimens. On Papanicolaou-stained Millipore filters, the most common finding was a yellow-brown-pigmented muriform conidium with characteristic transverse and longitudinal septations. Four of the patients had floccose branched and septated hyphae of Alternaria in addition to conidia. Budding yeast or yeast forms were also present in the lavage fluid of 14 of the patients with Alternaria. Two patients had concurrent Pneumocystis carinii pneumonia, and one patient had cytomegalovirus pneumonitis. No patient developed clinical features of systemic Alternaria infection, and autopsy of four patients did not reveal pneumonia. Alternaria conidia in a bronchoalveolar lavage fluid will usually represent laboratory contaminants or nonpathogenic saprophytes, and their significance lies in distinguishing them from other fungi. However, the expanded use of immunosuppressive therapy and the increasing prevalence of acquired immune deficiency syndrome may render such saprophytes clinically important.

Bronchoalveolar lavage: radiographic manifestations

Bronchoalveolar lavage (BAL) is a safe and well-tolerated procedure in which the lower respiratory tract is sampled through infusion and subsequent aspiration of sterile saline solution. To determine the radiographic changes consequent to this procedure, 25 patients undergoing fiberoptic bronchoscopy and BAL were evaluated prospectively. After lavage, anteroposterior radiographs were obtained immediately and after 30, 90, and 240 minutes, and 24 hours. The degree and site of opacification on the radiographs was graded on a 4+ subjective scale. Sixty-nine lobes were lavaged, but owing to overlap on the radiographs, 52 projected areas were evaluable for radiographic changes. Forty-seven areas of consolidation were identified on the radiographs obtained immediately after lavage. Consolidation was homogeneous and always corresponded to a projected site of lavage. There was a positive correlation between initial opacity on the radiograph and the volume of retained fluid (rs = .60, P less than .001). Consolidation cleared gradually over 24 hours. No patient had clinical pneumonitis. These benign, self-limited radiographic changes are common after BAL and may simulate pulmonary edema, aspiration, or hemorrhage.

Role of chemotactic factor inactivator in modulating alveolar macrophage-derived neutrophil chemotactic activity

The stimulated alveolar macrophage is a potent source of neutrophil chemotactic activity. The release of this chemotactic activity can be inhibited by pretreating alveolar macrophages with anti-C5 antibody. We hypothesized that C5a, a fragment cleaved from C5 when C5 is activated, might activate the alveolar macrophage to release neutrophil chemotactic activity and that chemotactic factor inactivator, a serum inhibitor of C5a, could decrease this release. Activated complement components including C5a were found to stimulate guinea pig macrophages to release chemotactic activity into their culture supernatants at levels that were significantly higher than the chemotactic activity of C5a alone (P less than 0.001). Chemotactic factor inactivator was found to cause a marked reduction in the chemotactic activity released by macrophages stimulated with phagocytic and nonphagocytic stimuli (P less than 0.001, all comparisons). These data indicate that C5a can stimulate alveolar macrophages to release chemotactic activity in vitro, and that chemotactic factor inactivator may play a role in modulating this process.

Cyclooxygenase metabolites are compartmentalized in the human lower respiratory tract

Cyclooxygenase metabolites of arachidonic acid are thought to play an important role in the regulation of diverse physiological functions in the lung. Although the concentration of these metabolites required to have effects is several orders of magnitude greater than the concentration of these mediators in the blood, it has been postulated that local concentrations within tissues are much higher. In a direct test of this hypothesis, the concentrations of the cyclooxygenase products of arachidonic acid including prostaglandin (PG) E, PGF2 alpha, 6-keto-PGF1 alpha, and thromboxane B2, were measured in a specialized tissue compartment, the epithelial surface of the lower respiratory tract. The concentration of these mediators within this compartment was 50- to 80-fold greater than concurrent blood levels and are sufficient to likely have physiological effects. Thus the epithelial surface of the lower respiratory tract represents a specialized compartment with high local levels of cyclooxygenase products of arachidonic acid.

Smoking intervention: combination therapy using nicotine chewing gum and the American Lung Association's "Freedom from Smoking" manuals

The smoking cessation efficacy of a two-session group program using the American Lung Association's "Freedom from Smoking" self-help manuals, nicotine gum, and brief, repeated professional supervision was estimated in an uncontrolled clinical trial. Of the 39 participants, 12 (31%) remained cigarette free for 1 year, and 4 others (10%) had not smoked during the 3 months prior to the 1-year follow-up. Claims of cessation were verified by expired-air carbon monoxide measurement. Nearly all successful abstainers were able to achieve 48-hr cessation during their first week using the gum. This finding suggests that nicotine gum is best used to help the smoker quit abruptly, rather than as an aid in a tapering-off strategy. This study's smoking intervention program appears to provide a relatively low-cost method of improving the success rates among smokers who wish to quit.

Familial idiopathic pulmonary fibrosis. Evidence of lung inflammation in unaffected family members

We evaluated 17 clinically unaffected members of three families with an autosomal dominant form of idiopathic pulmonary fibrosis for evidence of alveolar inflammation. Each person in the study was examined by gallium-67 scanning for a general estimate of pulmonary inflammation, and by bronchoalveolar lavage for characterization of the types of recovered cells and their state of activation. Eight of the 17 subjects had evidence of alveolar inflammation on the lavage studies. Supporting data included increased numbers of neutrophils and activated macrophages that released one or more neutrophil chemoattractants, and growth factors for lung fibroblasts--findings similar to those observed in patients with overt idiopathic pulmonary fibrosis. Four of these eight also had a positive gallium scan; in all the other clinically unaffected subjects the scan was normal. During a follow-up of two to four years in seven of the eight subjects who had evidence of inflammation, no clinical evidence of pulmonary fibrosis has appeared. These results indicate that alveolar inflammation occurs in approximately half the clinically unaffected family members at risk of inheriting autosomal dominant idiopathic pulmonary fibrosis. Whether these persons with evidence of pulmonary inflammation but no fibrosis will proceed to have clinically evident pulmonary fibrosis is not yet known.

Human type III collagen gene expression is coordinately modulated with the type I collagen genes during fibroblast growth

Type III collagen is one of the major interstitial collagens and, as such, plays an important role in modulating the structure and function of most tissues. To compare the expression of the type III collagen gene to that of the type I collagen alpha 1(I) and alpha 2(I) genes, cDNAs encoding the 3' one-third of the human alpha 1(III) collagen mRNA were obtained by screening a human fetal lung fibroblast cDNA library with a cloned segment of the chicken alpha 1(III) gene. Northern blot analysis of human fetal lung fibroblast RNA demonstrated two alpha 1(III)-specific mRNAs of sizes 6.6 and 5.8 kilobases, sizes clearly different from those of the type I collagen mRNAs. Analyses of populations of dividing and nondividing human lung fibroblasts revealed that, on a per cell basis, the nondividing population contained twice as much alpha 1(III) mRNA than did the dividing population. The same was true for the type I collagen alpha 1(I) and alpha 2(I) mRNA transcripts. Similar results were obtained when alpha 1(III), alpha 1(I), and alpha 2(I) mRNA transcripts were quantified by using dot blot evaluation of total RNA, Northern analysis of total RNA, and dot blot evaluation of cytoplasmic RNA. Thus, despite the fact that the alpha 1(III) collagen gene is located on a chromosome different from the alpha 1(I) and alpha 2(I) genes, the expression of these three collagen chains appears to be coordinately controlled during periods of rapid and slow fibroblast growth.

Modulation of alveolar macrophage-driven fibroblast proliferation by alternative macrophage mediators

Tissue fibrosis results, in part, from an interaction between growth regulatory molecules released by mononuclear phagocytes and fibroblasts. In the chronic interstitial lung disorders, alveolar macrophages, the mononuclear phagocytes of the lung, are known to spontaneously release two growth factors for fibroblasts, fibronectin and alveolar macrophage-derived growth factor (AMDGF) that together stimulate nonreplicating lung fibroblasts to divide. In addition to these two primary growth promoting signals, alveolar macrophages are able to release other mediators that may have a potential role in modulating lung fibroblast replication in response to these primary signals, including interferon gamma (IFN gamma), prostaglandin E2 (PGE2), and interleukin 1 (IL-1). To evaluate this possibility, we examined the effect of each of these other mediators on lung fibroblast replication in response to fibronectin and AMDGF in serum-free, defined medium. IFN gamma had no effect on fibroblast replication. In contrast, PGE2 resulted in a dose-dependent inhibition of fibroblast replication in response to fibronectin and AMDGF with 50% of the maximum inhibition observed at a PGE2 concentration of less than 10 ng/ml. IL-1, while not active as a primary growth promoting signal, at concentrations of 4-10 U/ml, augmented fibroblast replication in response to fibronectin and AMDGF by 10 to 15%. Temporally, the growth augmenting effect of IL-1 occurred early in the G1 phase of the cell cycle. These data indicate that lung fibroblast replication in response to two of the primary growth promoting signals spontaneously released by alveolar macrophages in the interstitial lung disorders, while uninfluenced by IFN gamma, can be inhibited by PGE2 and modestly augmented by IL-1. Understanding the relevant fibroblast growth modulatory signals within the alveolar microenvironment in the chronic interstitial disorders may lead to rational therapeutic strategies designed to interrupt the fibrotic process.