Long-term nocturnal mechanical ventilation in patients with kyphoscoliosis

THE AIMS OF OUR STUDY WERE

1) to evaluate the long-term efficacy of nocturnal IPPV either via tracheostomy (tIPPV) or a nasal mask (nIPPV) as a means to improve alveolar ventilation in patients with chronic severe hypercapnia caused by kyphoscoliosis; and 2) to assess the effect of MV on hospitalizations and life-style. Twenty six patients with kyphoscoliosis in chronic respiratory failure were enrolled in the study. Patients were divided into two groups. The first group comprised 13 subjects who had been clinically stable for at least 1 month (arterial carbon dioxide tension (Pa,CO2) 81 +/- 1.5 kPa (60.8 +/- 10.9 mmHg), arterial oxygen tension (Pa,O2) 7.3 +/- 0.8 kPa (54.6 +/- 6.1 mmHg)). The second group comprised 13 patients who were either suffering or recovering from an episode of acute respiratory insufficiency (Pa,CO2 9.0 +/- 1.8 kPa (67.8 +/- 13.3 mmHg), Pa,O2 6.8 +/- 1.1 kPa (51.2 +/- 8.2 mmHg), breathing supplemental oxygen in seven cases). Patients in the first group were treated with nocturnal IPPV via a nasal mask, whilst those in the second received nocturnal IPPV via tracheostomy. Similar improvements in arterial blood gases (ABGs) were achieved with both methods. Despite the differences in the degree of severity at baseline, after 1 month, ABG values were: Pa,CO2 6.2 +/- 0.6 kPa (46.6 +/- 4.4 mmHg), Pa,O2 9.0 +/- 1.3 kPa (67.5 +/- 9.6 mmHg) (nIPPV patients); Pa,CO2 6.1 +/- 0.9 kPa (46.1 +/- 6.8 mmHg), Pa,O2 9.8 +/- 1.3 kPa (73.6 +/- 9.8 mmHg) (tIPPV patients). After 1 yr, this improvement was still evident. Days of hospitalization were significantly reduced in both groups during the first year of MV. We conclude that both tIPPV and nIPPV are effective in the long-term treatment of respiratory failure in patients with kyphoscoliosis. It would appear from our data that if nIPPV is initiated early in the evolution of chronic respiratory failure in patients with kyphoscoliosis it will delay the necessity to use an invasive technique; however, long-term follow-up studies and larger case series are needed to demonstrate this.

Airways inflammation in subjects with chronic bronchitis who have never smoked

BACKGROUND

Smoking is the single most common cause of chronic bronchitis but the disease can also occur in non-smokers. Alterations in the lung responsible for the disease, such as oxidant/antioxidant and protease/antiprotease imbalance, have been investigated in smokers. The aim of our study was to evaluate local cellular and soluble factors (albumin, immunoglobulins, proteases, alpha 1-antitrypsin, and transferrin) that may be involved in the development of chronic bronchitis in subjects who have never smoked.

METHODS

Sixteen clinically stable patients with chronic bronchitis who had never been smokers were studied and 17 healthy non-smokers served as controls. All subjects underwent bronchoalveolar lavage (BAL). Total and differential cell counts and concentrations of the main proteins (albumin, immunoglobulins, complement fractions, alpha 1-antitrypsin, and transferrin) were measured. Elastase-like activity was assessed in cells and supernatants. To estimate the oxidant burden the release of superoxide anion (O2-) from native cell populations was evaluated.

RESULTS

Recovery of BAL fluid was reduced in older individuals in both the chronic bronchitis and control groups. There was no difference in total cell count, but neutrophil percentage count was higher in those with chronic bronchitis (median (range) 3.5 (1.6-14.2)) than in controls (1.3 (0.5-3.7)). These differences were most pronounced in the first recovery, representative of the bronchial lavage. There was no difference in bronchial epithelial cells. Total proteins and albumin levels were comparable and IgG, IgA, IgM, C3, C4, transferrin and alpha 1-antitrypsin values standardised to albumin did not show any significant differences. No differences in elastase-like levels in supernatants were detected. In cell lysates elastase-like activity x 10(7) cells (macrophages+neutrophils) was increased in patients with chronic bronchitis (0.25 (0.06-4.3) compared with controls 0.08 (0.03-0.9) micrograms PPEeq). The release of O2- both at baseline and after opsonised zymosan phagocytosis did not show any differences. Correlation analysis between FEV1 and BAL fluid data showed a negative correlation only with neutrophils/ml.

CONCLUSIONS

Clinically stable non-smokers with chronic bronchitis show no alterations of local immune components, oxidant burden, and free elastase-like activity in BAL fluids, while the content of elastase-like activity in phagocytic cells is increased. As in smokers, bronchial neutrophilia is the most significant cellular modification which correlates with the degree of airflow obstruction.

Local airways immune modifications induced by oral bacterial extracts in chronic bronchitis

Bacterial extracts can act as immune stimulants and in some instances have been used, rather empirically, to prevent recurrent infections in the nonimmunocompromised host. Some agents are administered via oral route with the goal to increase airways immune defenses. In animal models and in normal humans, gut-associated lymphoid tissue (GALT) stimulation is able to induce a generalized response by the whole mucosal-associated lymphoid tissue (MALT). The aim of this placebo-controlled, double-blind, parallel-group study was to evaluate whether the stimulation of the GALT through oral administration of a polyvalent bacterial extract (BE) could lead to significant immune modifications either systemically or locally in the respiratory tract in patients suffering from chronic bronchitis. We selected 20 subjects (5 nonsmokers, 6 smokers, and 9 ex-smokers) for at least 3 years. According to a balanced-block randomization method, ten patients received active treatment and ten received placebo. Either drug or placebo was to be taken as one capsule daily the first 10 days of 3 consecutive months. Each capsule of the active product contained 7 mg of a BE obtained from eight different bacterial strains. On entry (T0) and 90 days after beginning of treatment (T90), all patients underwent bronchoalveolar lavage (BAL) and peripheral blood withdrawal to assay BAL fluids and serum samples for immune parameters. The BAL recoveries, cellularity, cell differentials, and lymphocyte subsets (CD19, CD3, CD4, CD8) did not show significant differences. IgG/albumin and IgA/albumin values were not significantly different, but IgA/albumin was significantly increased in the treatment (T0 = 0.14, 0.01 to 0.27, median and range, T90 = 0.15, 0.08 to 0.45, p = 0.028) vs the placebo group when data from current smokers were excluded. Functional tests on alveolar macrophages (AM) (leading front stimulated motility and superoxide anion-O2(-)-release) showed a significant increase of random migration (T0 = 10.6, 7.0 to 23.6, T90 = 13.4, 8.1 to 28.8 microns, p = 0.02) and of stimulated motility after FMLP 10(-7) M (T0 = 13.2, 8.3 to 46.4, T90 = 18.3, 8.4 to 49.6 microns, p = 0.04), a significant increase of O2- release in basal conditions (T0 = 6.0, 1.7 to 30.5 nM/10(6) AM/10', T90 = 11.1, 5.5 to 24.5, p = 0.05) and after stimulation with opsonized zymosan (T0 = 17.7, 4.7 to 35.2, T90 = 22.1, 13.8 to 53.3, p = 0.009) in the treatment group only. Data were not significantly different in the placebo group between T0 and T90. No modifications in systemic immunity were ever observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Proposal of an easy method to improve routine sputum bacteriology

The study of bacterial flora of the lower respiratory tract is very important for the diagnosis of pulmonary infections and proper therapy but it has to face important methodologic problems. The main problem is contamination of the sputum during its passage through the upper airways. The present study suggests an improved procedure aiming first of all at reducing the specimen contamination by upper airway bacteria by means of a preliminary mouth wash, and secondly at comparing qualitative and quantitative cultures of spit with those of sputum. In our study bronchial lavage aspirate (BLA) cultures were used as a control. Both definite (80 patients) and random (20 patients) sequence sampling procedures were considered to show the importance of a correct sequential specimen collection. Bacteria isolated in the sputum and/or in BLA but absent in the spit were considered the most probable responsible for an eventual pulmonary infection. On the contrary a germ found in the spit and eventually in the sputum but not in BLA was considered responsible for only an eventual inflammation of the upper respiratory tract. Doubtful cases were solved by comparing the different bacterial concentrations in the various samples. A preliminary mouth washing procedure decreased the mean concentration of contaminants in the sputum: 3.6 +/- 7.5 x 10E8 (E = exponent) versus 3.7 +/- 7.2 x 10E7 CFU/ml spit versus sputum (80 patients) p less than 0.001. On the contrary if sputum preceded spit (12 out of the 20 randomly treated subjects), bacterial counts were not significantly different (2.1 +/- 5.7 x 10E8 vs. 1.3 +/- 2.9 x 10E8 CFU/ml, respectively, p = NS). In the group of correctly treated patients (80 subjects) only infrequently oral contaminants were found in BLA (12.5%). The finding of bacteria in BLA but absent in spit and/or sputum was rare (4.8%) suggesting that, at least in chronic obstructive lung disease (COLD) patients, spit and sputum quantitative and qualitative cultures may be sufficient for a good microbiologic examination in almost all the cases.

[Functional recovery in pulmonary tuberculosis]

At first Authors explain the stages of tubercular disease in which a programme of functional respiratory rehabilitation can be advised. Then they deal with the main aspects of rehabilitating treatment in some tubercular manifestations, as sero-fibrinous pleural effusion, tubercular empyema, parenchymal fibrosis and surgical reliquates. With regard to surgical reliquates, we mostly consider pulmonary resections and pleural skinning. At last Authors recall the indications to physical exercise training, that are constituted by some reliquates of tubercular pathology, and they resume the accomplishment modalities of such a programme in order to allow every patient wide possibilities of social reintroduction.

[Rehabilitation of the worker with bronchopneumopathy]

Epidemiological data show that chronic diseases of the respiratory apparatus have constantly increased over the last 20 years or so, often involving relatively young age classes. The increased survival rates due to chemotherapy also increase the importance of rehabilitation in such diseases. The officially accepted concept of a "global" rehabilitation is particularly significant in the case of patients of working age. The main rehabilitation procedures include chest physiotherapy, aerosol therapy, oxygen therapy (where selection criteria have been established and where there are new prospects related to long-term oxygen therapy), intermittent positive pressure breathing and physical retraining. Details on the methods of assessment and training and data concerning three groups of patients suffering from respectively chronic obstructive lung disease, silicosis and asbestosis, are given. The data show a general pattern of a decrease in ventilation (for an unchanged level of O2 uptake and CO2 output) and reflect a rise in muscular efficiency (exercising and respiratory) enabling the body to perform the same work load at a lower energy cost. The authors discuss the vocational rehabilitation of the patient with lung disease and illustrate the most useful procedures in the assessment of the subject, the environment and the place of work, including guidelines to achieve this. Rehabilitation treatment is also summarized into a number of stages, with the goals at different therapeutic levels and the ways to reach them.