The Clinical and Physiological Effect of Whole-Lung Lavage in Pulmonary Alveolar Proteinosis: A Ten-Year Experience

We have utilized whole-lung lavage in the successful treatment of 18 patients with pulmonary alveolar proteinosis. Our ten-year experience includes serial evaluations of patients with disabling lung dysfunction who had a total of 49 whole-lung lavages under general anesthesia. Clinical and physiological responses were documented both before and after each lavage. There were no complications or deaths. All patients were radiographically, physiologically, and symptomatically improved within hours after the procedures. Five patients required from two to four repeat lavages one to three years later.The treatment of this disorder has included a wide variety of techniques. We attribute our results to the use of a lung lavage technique that includes: (1) unilateral whole-lung lavages at two to three day intervals; (2) isotonic saline as the lavage solution; (3) use of a mechanical chest percussor during lavage; and (4) measuring the total thoracic compliance of each side in the immediate postlavage period as a guide for extubation. We conclude that whole-lung lavage is a safe, highly effective, repetitively applicable treatment for pulmonary alveolar proteinosis.     

Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension

Transcutaneous oxygen tension (P_tcO₂) was used for noninvasive determination of blood supply in 25 patients evaluated for peripheral arterial disease. p_tcO₂ values were compared with segmental Doppler pressure, pulse volume recording, pulse reappearance time, and angiography in patients being evaluated for wound healing problems, amputations, and peripheral bypass procedures. P_tcO₂ was measured using a heated (45 °C) Clark polarographic electrode to quantitate the oxygen which diffuses from the dermal capillaries to the skin surface. Control P_tcO₂ values recorded over the chest or shoulder taken while patients were breathing room air were 78 ± 8 mm Hg. P_tcO₂ values greater than 50 mm Hg predicted success for levels of amputation and for wound healing without reconstructive procedures; values of 40 mm Hg or less were associated with continued wound problems and complication after amputation. Increased P_tcO₂ values after vascular reconstruction of the legs predicted improved clinical status on follow-up examinations up to 6 months. P_tcO₂ predicted the extent of vascular disease as well as the other noninvasive tests and angiography. We conclude that (1) P_tcO₂ tension is a simple, accurate, noninvasive method to determine the appropriate level of amputation, wound healing potential, and effectiveness of bypass procedures, and (2) P_tcO₂ values correlate well with angiography and noninvasive evaluations.     

Bronchopulmonary fluids in pulmonary alveolar proteinosis

The alveoli of patients with pulmonary alveolar proteinosis (P.A.P.) become filled with a proteinaceous material, the origin of which is uncertain. The purpose of this study was to examine bronchopulmonary washings from four adults and one child with this disease who had total lung lavage for treatment of the hypoxemia caused by the disease process. In each instance a liter or more of lavage fluid was concentrated approximately four hundred fold by ultrafiltration for protein analysis. Quantitative determinations of the proteins in this fluid and in serum were performed in quadruplicate by the Lowry method, radial diffusion, or radioimmunoassay. There was a selective increase of IgG in washings from all five patients with P.A.P., and there was a lesser increase of IgA, suggesting either a local production or a mechanism for concentrating these immunoglobulins. Albumin usually comprised a similar proportion of the total protein in serum and washings, but alpha-2 macroglobulin comprised less than half that in serum in each instance, suggesting that equal transudation of large and small proteins did not occur. There was considerable variation in the relative proportion of IgM, IgD, and IgE in washings compared to serum, suggesting that each of these immunoglobulins is metabolized (synthesized, transported, or catabolized) by an independent mechanism in the lung. Secretory piece was demonstrated in the bronchial washings of each patient, including controls, as were two soluble nonserum proteins. Fibrinogen was identified in the washings of the three patients with P.A.P. Large amounts of insoluble surfactant-like material were also present in the washings of each of the patients with P.A.P.     

Alpha1-antitrypsin in amniotic fluid and cord blood of preterm infants with the respiratory distress syndrome.

Total protein, alpha1-antitrypsin, and alpha2-macroglobulin were measured on amniotic fluid in 125 pregnancies between 11 and 42 weeks' gestation, and on the cord blood of 66 newborn infants. Amniotic fluid surface active material was assessed by the foam stability test. Amniotic fluid alpha1-antitrypsin is linearly and directly related to amniotic fluid total protein (r = 0.703, p less than 0.001). The cord alpha1-antitrypsin is also linearly related to cord total protein. Intrapartum complications are associated with a significant lowering of the cord alpha1-antitrypsin. Infants with a negative foam stability test had RDS regardless of the amniotic fluid alpha1-antitrypsin. The cord blood alpha1-antitrypsin value did not appear to be related to amniotic fluid surface active material. There were 23 infants with cord alpha1-antitrypsin of less than 0.2 gm/dl and with an intermediate or positive foam stability test; 19 of them had respiratory difficulties of varying severity. It is conceivable that infants, in spite of apparent adequate prenatal lung surfactant, develop respiratory disturbances on the basis of pulmonary fluid and protein transudation and/or reduction or inhibition of pulmonary surfactant incident to intrapartum complications.     

The oxytocin secretory response to breast stimulation in women during the menstrual cycle

Plasma oxytocin concentrations were measured during 12 minutes of mechanical pump stimulation in nine healthy women during the follicular and luteal phases of the menstrual cycle. In the follicular phase (and in five healthy male subjects), plasma oxytocin values did not increase above baseline levels with breast pump stimulation. In contrast, pump stimulation evoked a significant increase in plasma oxytocin levels during the luteal phase of the menstrual cycle. These observations suggest that oxytocin secretion is modulated by hormones involved in the menstrual cycle in women.     

Peroperative pancreatic aspiration for evaluating pancreatic disease

Nineteen patients who underwent peroperative pancreatic aspiration during 1976 to 1978 were retrospectively compared with 19 other consecutively chosen patients who underwent pancreatic surgery without this procedure in 1973 and 1974. In 18 of the 19 patients who had pancreatic aspiration, an accurate diagnosis was obtained. Three patients in the 1973 to 1974 series had serious postoperative complications attributable to incorrect intraoperative diagnosis and subsequent operative therapy. Peroperative pancreatic aspiration cytology provides a definitive diagnosis that may result in the most efficacious therapy for pancreatic disease.