Penetration of cefaclor into bronchial mucosa.

Bronchial mucosal biopsy specimens were obtained during fibreoptic bronchoscopy in 30 patients receiving a new oral cephalosporin antibiotic, cefaclor (10 had 250 mg, 10 had 500 mg, and 10 had 1000 mg every eight hours). In 10 patients (from all dosage groups) cefaclor was undetectable in the bronchial mucosa but in every case the serum concentration was low, suggesting incomplete absorption. The mean (SD) bronchial mucosal concentration after 250 mg was 3.78 (1.77) micrograms/g (range 2.1-5.8 micrograms/g, n = 4), after 500 mg 4.43 (2.04) micrograms/g (range 2.0-7.1 micrograms/g, n = 8), and after 1000 mg 7.73 (2.76) micrograms/g (range 5.0-12.7 micrograms/g, n = 6). A significantly higher concentration in the bronchial mucosa was achieved with 1000 mg than with 250 mg (p less than 0.05) or 500 mg (p less than 0.025). These concentrations should be effective against Streptococcus pneumoniae, most strains being inhibited below 1.0 microgram/ml. The concentrations were within one dilution of the minimal inhibitory concentration for Haemophilus influenzae, most strains being inhibited below 4.0 micrograms/ml. Some strains of H influenzae will not be inhibited by the concentrations of cefaclor found in the bronchial mucosa, particularly those that are ampicillin resistant.     

Changes in day and night time oxygenation with protriptyline in patients with chronic obstructive lung disease.

The effect of protriptyline, a tricyclic antidepressant, on sleep architecture, nocturnal arterial oxygen desaturation, pulmonary function, and diurnal arterial blood gases was investigated in an open study of 14 patients with stable chronic obstructive lung disease. Daytime and overnight measurements were made before and 2 and 10 weeks after they started protriptyline (20 mg daily at bedtime). Two patients had to be excluded before the second visit and one before the third visit because of changes in treatment for their chest disease. Protriptyline caused mouth dryness in all patients and dysuria in six men. With protriptyline there were no significant changes in total sleep time, sleep period time, or the percentages of total sleep time occupied by stage I-II and stage III-IV sleep. The mean (SEM) percentage of total sleep time spent in rapid eye movement (REM) sleep decreased from 11.1 (1.7) to 4.6 (0.7) at two weeks and to 4.2 (1.0) at 10 weeks. After protriptyline the time spent during sleep with an arterial oxygen saturation (SaO2) below each 5% increment above 65% was less than the baseline time; the lowest SaO2 (%) reached during sleep increased from 64.5 (1.7) to 72.7 (2.1) at 2 weeks and to 77.4 (2.1) at 10 weeks. Lung volumes and expiratory flows were unchanged during the study. Daytime arterial oxygen tension (PaO2) increased from 57 (1.4) mm Hg before treatment to 62 (1.9) mm Hg at 2 weeks and to 66 (1.9) mm Hg at 10 weeks (7.6 (0.2), 8.3 (0.3), 8.8 (0.3) kPa). Carbon dioxide tension fell from 52 (2.3) mm Hg to 49 (1.4) mm Hg at 2 weeks and to 48 (2.0) mm Hg at 10 weeks (6.9 (0.3), 6.5 (0.2), 6.4 (0.3) kPa), but these changes were not significant. These results suggest that protriptyline may benefit patients with chronic obstructive lung disease by reducing the sleep induced falls in SaO2 and improving diurnal PaO2; a controlled trial is now required.     

An update on bronchial blockers during lung separation techniques in adults

Techniques for one-lung ventilation (OLV) can be accomplished in two ways: The first involves the use of a double-lumen endotracheal tube (DLT). The second involves blockade of a mainstem bronchus (bronchial blockers). Bronchial blockade technology is on the rise, and in some specific clinical situations (e.g., management of the difficult airway during OLV or selective lobar blockade) it can offer more as an alternative to achieve OLV in adults. Special emphasis on newer information for the use of Fogarty embolectomy catheter as a bronchial blocker, the torque control blocker Univent, and the wire-guided endobronchial blocker (Arndt blocker) is included. Also this review describes placement, positioning, complications, ventilation modalities, and airflow resistances of all three bronchial blockers. Finally, the bronchial blockers can be used in many cases that require OLV, taking into consideration that bronchial blockers require longer time for placement, assisted suction to expedite lung collapse, and the use of fiberoptic bronchoscopy. The current use of bronchial blockers, supported by scientific evidence, dictates that bronchial blockers should be available in any service that performs lung separation techniques.     

Changes in calf muscle function in chronic venous disease.

The aim of this study was to assess calf muscle function in patients with chronic venous disease and recently healed venous ulcers. Forty-nine consecutive patients with recently healed proven venous leg ulcers and 20 age- and sex-matched control subjects were entered into this study. Both patients and control subjects underwent duplex scan evaluation of their leg veins and isokinetic measurement for calf muscle strength and endurance. Calf muscle function was significantly impaired in patients with chronic venous disease compared with control subjects. Both peak torque/body weight (strength), P = 0.049 (CI 0.3-18.4%) and total work (endurance), P = 0.05 (Cl 6.01-97.6 Nm) were reduced. This study has shown that patients with chronic venous disease have a significant impairment of calf muscle function compared with healthy control subjects. This study suggests that there is a need to evaluate whether a programme to improve muscle strength may be of benefit in both healing and preventing the recurrence of chronic venous ulcers.     

Normal bronchial healing without bronchial wrapping in canine lung transplantation.

The deleterious effect of steroids on bronchial healing in lung transplantation has led to the development of techniques to protect the anastomosis and to the exclusion of steroid-dependent patients from transplantation. The effect of steroids on bronchial healing was tested in a canine single-lung allotransplantation model. Twenty size-matched mongrel dogs (20 to 30 kg) underwent left lung transplantation without anastomotic wrap or direct revascularization. Postoperatively, all received daily doses of cyclosporine (15 mg/kg) and azathioprine (1 mg/kg) and were subdivided into three steroid dosage groups. Group A (n = 10) animals received 1.5 mg/kg of prednisone per day whereas groups B (n = 5) and C (n = 5) received 5.0 mg/kg of prednisone per day for 28 postoperative days. In addition, group C received prednisone (5.0 mg.kg-1.day-1) for 1 month preoperatively. In group A, 8 of 10 dogs survived 28 days without evidence of respiratory compromise, with anastomotic bursting pressure greater than 510 mm Hg. In group B, all 5 dogs survived to 28 days without evidence of respiratory compromise and with intact bronchial anastomoses (bursting pressures greater than 510 mm Hg). In group C, 3 of 5 animals survived to 28 days with intact anastomoses. Histological examination demonstrated normal bronchial healing in all anastomoses. These data suggest that preoperative steroid dependence should not be a contraindication to lung transplantation and that bronchial anastomotic wrapping with vascular tissue may not be essential.     

Errors in the measurement of total lung capacity in chronic obstructive lung disease.

The standard plethysmographic method of measuring total lung capacity (TLC) has been reported to result in spuriously high estimates in patients with severe airway obstruction. The helium-dilution method is known to underestimate TLC in the same patients. To determine the magnitude of these possible errors we measured TLC by four methods in 20 patients with varying degrees of chronic obstructive lung disease and in 11 normal subjects. TLC was measured by (1) helium dilution (TLCHe); (2) a volume-displacement body plethysmograph, box volume being plotted against mouth pressure (TLCm); (3) the same body plethysmograph with volume plotted against pressure measured with an oesophageal balloon (TLCes); and (4) a radiological technique (TLCxr). In normal subjects there was no difference between TCLm (6.57 +/- 1.20) and TLCes (6.51 +/- 1.24). In the patients with chronic obstructive lung disease TLCm gave results significantly higher than those of any other method. If TLCes is taken as the closest estimate of true TLC, TLCm consistently overestimates and TLCHe underestimates TLC. There was no relationship between the degree of airway obstruction and (TLCm - TLCes) but there was between (TLCes - TLCHe) and severity of airway obstruction. We conclude that using mouth pressure in the plethysmographic measurement of TLC in patients with chronic obstructive lung disease results in consistent but slight overestimation of TLC.     

Changes in lung lobar volume and bronchial deformity after right upper lobectomy

n = 10) and A2 (n = 10) were control groups and groups B1 (n = 10) and B2 (n = 10) underwent RU lobectomy. Casting material was introduced into the airway and a heart-lung bloc was removed form the thoracic cavity in all groups. In groups A1 and B1, the volume of each lobe of the bilateral lungs was measured, while in groups A2 and B2, bronchial casts were made and the branching angles of the airway were measured. The volume ratio of the right upper lobe (RUL) to the total lung was 12.0 ± 0.4% in group A1; however, after RU lobectomy, the volume ratio of the right middle lobe (RML) to the total lung increased from 8.7 ± 0.6% in group A1 to 13.5 ± 0.8% in group B1. The volume of the left lung also increased from 43.0 ± 0.5% in group A1 to 48.8 ± 1.1% in group B1. The angle between the truncus intermedius and the RML bronchus was significantly smaller in group B2, at 109.0 ± 3.5°, than in group A2, in which it was 138.5 ± 1.7°. The angle between the RML bronchus and the coronal plane was 57.5 ± 2.5° in group A2 and 33.5 ± 3.3° in group B2. Our method of measuring the bronchial branching angle subsequent to RU lobectomy proved useful to illustrate postoperative positional changes and expansion of the remaining lobes. (Received for publication on Oct. 21, 1996; accepted on May 12, 1997)     

Intravenous prednisolone in chronic bronchial asthma.

A single injection of 40 mg prednisolone phosphate was given to 10 patients with chronic bronchial asthma. Changes in pulmonary function were followed over a 30-hour period. Statistically significant changes occurred in the tests employed one hour after the injection of prednisolone. The maximum change for the group as a whole was seen to occur after eight hours. This time course of response is very similar to that obtained in previous studies on similar groups of patients with oral prednisolone where the peak effect occurred nine hours after the drug had been given. Intravenous hydrocortisone produces a much earlier peak effect, at five hours, when it is administered to chronic asthmatic patients.     

Residual disease at the bronchial stump after curative resection for lung cancer.

The most important surgical goal during potentially curative surgery for non-small cell lung cancer (NSCLC) is a macroscopic and microscopic radical resection (R0-resection). Studies reporting on recurrence and long-term survival mainly comprise patients with completely resected NSCLC (R0-resection). However, there is limited data on incidence, treatment and prognosis of patients with microscopic residual tumour tissue at the bronchial resection margin (R1-resection). Furthermore, the definition of an R1-resection of the bronchial resection margin is not uniform in literature. Based on 19 studies published between 1945 and 2003 with a substantial number of included patients with resected NSCLC, the incidence of an R1-resection of the bronchial resection margin is approximately 4-5% (range 1.2-17%) of all lung resections. Divided into the localisation of the microscopic residual disease, survival of patients with carcinoma in situ (CIS) at the bronchial resection margin is comparable to the survival after a radical resection. The prognosis is negatively influenced in case of microscopic mucosal residual disease. Survival is even worse in patients with peribronchial residual disease; 1- and 5-year survivals range between 20-50% and 0-20%, respectively. This poor prognosis is because peribronchial residual disease, in 75-85% of the patients, is associated with mediastinal lymph node metastasis. According to the stage, survival of patients with stage I and II NSCLC and an R1-resection of the bronchial resection margin is significantly worse as compared to stage-corrected survival after a radical resection. In these patients, survival is limited due to local recurrence. The negative effect of an R1-resection of the bronchial margin in stage III NSCLC is limited, as these patients die due to disseminated disease (distant metastasis) before local recurrence occurs. A conservative approach with frequent bronchoscopic surveillance is justified for CIS. For patients with microscopic residual disease at the bronchial margin and stage I and II NSCLC, further treatment has to be considered. Adjuvant treatment in patients with stage III NSCLC has no proven benefit in terms of survival.     

Monogenic causes of chronic kidney disease in adults

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Increased incidence of pulmonary tuberculosis in chronic interstitial lung disease.

Of 162 patients with chronic interstitial lung disease, eight (seven of them male) had active tuberculosis. This was 4.5 times higher than the incidence in the general population. The frequency of tuberculosis was similar in patients treated with and without corticosteroids.     

Low grade neuroendocrine tumors of the lung (bronchial carcinoids)--25 years experience

From 1960 to 1986, 69 patients with low grade neuroendocrine tumours (LGNT) of the lung were admitted to our institution. Of these, 36 were male and 33 were female. The mean age was 43 years with a range of 9-76 years. Sixty-eight patients were operated upon of whom 11 had metastatic mediastinal lymphnodes. A complete follow-up ranging from 3 to 25 years was obtained in 61 patients. Actuarial survival was 95% at 5 years and 87% at 10 years. The most important factor influencing the prognosis was mediastinal lymph node involvement. In 9 patients with mediastinal lymph node metastases at operation, the survival at 5 and 10 years was 75% and 46%, respectively, with highly significant difference (P less than 0.0001) as compared with the nonmetastatic group. In conclusion, bronchial LGNT are generally benign, but encompass a potential for malignancy. The prognosis depends on the presence of regional lymph node metastases. The choice of adequate surgical treatment depends on the size, location and aggressiveness of the tumour and the status of the mediastinal lymph nodes. The condition of the lung parenchyma distal to the lesion must be taken into account.