Adrian J. Williams

Sleep apnea syndrome and essential hypertension.

More than half of patients with essential hypertension have sleep apnea. The incidence of unrecognized sleep apnea in patients with essential hypertension was assessed. Twenty-three patients taking antihypertensive medication were selected at random from a hypertension clinic. They were evaluated by questionnaire for symptoms of sleep apnea, and during 3 hours of sleep, measurements were made of respiratory patterns using an impedance pneumograph, arterial O2 saturation with an ear oximeter and air flow at the mouth or nose with a face mask pneumotacograph. Abnormal sleep apneas (average 20 seconds) lasting for an average of 19% sleep time were found in 11 patients (48%). Significant arterial O2 desaturation, defined as a decrease of at least 4% and to less than 90%, was observed in 7 of these 11 (30%), with an average saturation of 87% at the end of the apneic episodes. Thus, almost one-third of patients randomly selected had significant arterial O2 desaturation during sleep because of sleep apnea, and it is suggested that sleep apnea may play a part in the development of essential hypertension.

Lung Growth and Airway Function after Lobectomy in Infancy for Congenital Lobar Emphysema

To characterize the outcome of lobectomy in infancy and the low expiratory flows which persist after lobectomy for congenital lobar emphysema, 15 subjects with this history were studied at age 8-30 yr. Total lung capacity was normal in all, but higher values (P < 0.05) were observed in nine subjects with upper lobectomy than in five subjects with right middle lobectomy. Ratio of residual volume to total lung capacity was correlated (P < 0.05) with the amount of lung missing as estimated from normal relative weights of the respective lobes. Xe(133) radiospirometry in eight subjects showed that the operated and unoperated sides had nearly equal volumes at total lung capacity, but that the operated side was larger than the unoperated side at residual volume. Perfusion was equally distributed between the two sides. Similar findings were detected radiographically in four other subjects. Forced expiratory volume in 1 s and maximal midexpiratory flow rate averaged 72 and 45% of predicted, respectively. Low values of specific airway conductance and normal density dependence of maximal flows in 12 subjects suggested that obstruction was not limited to peripheral airways. Pathologic observations at the time of surgery and morphometry of the resected lobes were not correlated with any test of pulmonary function. These data show that lung volume can be completely recovered after lobectomy for congenital lobar emphysema in infancy. The volume increase occurs on the operated side, and probably represents tissue growth rather than simple distension. The response to resection is influenced by the particular lobe resected and may be associated with decreased lung recoil near residual volume. Low expiratory flows in these subjects could be explained by several mechanisms, among which a disproportion between airway and parenchymal growth in infancy (dysanaptic growth) is most compatible with our data.

Bronchial atresia: A recognizable entity in the pediatric age group

Bronchial atresia, a congenital lesion that develops after the 16th wk of fetal life, may be more common than previously believed, and this probably explains some cases of so-called congenital lobar emphysema. It may produce symptoms of pulmonary infection, wheezing, and respiratory distress severe enough to justify elective resection of that part of the lung distal to the atresia. The roentgenographic features that make this a recognizable entity are the following: (1) There is localized hyperinflation of lung in a segmental or lobar distribution, with a circular or oval parahilar radiodensity. Bronchography will demonstrate that there is no filling of the bronchus supplying this part of the lung. (2) The occasional neonate with this condition may present with an intrathoracic mass suggesting retained fetal lung fluid in lobar distribution. Bronchography will demonstrate that there is no filling of the bronchus to that part of the lung. (3) A plug of desquamated tissue and mucus in the cyst-like bronchus just distal to the point of atresia appears to be an unvarying component of the syndrome. It most commonly presents as a round or oval density, but in some cases it may be shaped like a rod or tree and rarely contains an air-fluid level.

Polyalveolar lobe: anatomic and physiologic parameters and their relationship to congenital lobar emphysema.

Polyalveolar lobe is one of the recently described pathological entities that can give rise to congenital lobar emphysema (CLE). In polyalveolar lobe, the total alveolar number as determined by microscopic point-counting of randomly taken lung sections is increased three to fivefold. The airways and arteries are normal for age in number, size and structure. Follow-up over 10-20 yr of patients operated upon for congenital lobar emphysema, including those of polyalveolar lobe etiology shows that these patients do well clinically. All patients have some pulmonary function abnormalities, specifically a decrease in airway conductance, and forced expiratory volume. It is not possible to distinguish patients with polyalveolar lobes from other CLE patients on the basis of pulmonary function data. All patients had normal lung volumes and vital capacities, despite losing 8%-20% of their pulmonary parenchyma. Based on compensatory lung growth, it may be preferable to operate earlier, rather than later in these cases.

Hypoxia and hydrothoraces in a case of liver cirrhosis: correlation of physiological, radiographic, scintigraphic, and pathological findings

Stanley, N. N., Williams, A. J., Dewar, C. A., Blendis, L. M., and Reid, Lynne (1977).Thorax, 32, 457-471. Hypoxia and hydrothoraces in a case of liver cirrhosis: correlation of physiological, radiographic, scintigraphic, and pathological findings. A case is reported of liver cirrhosis complicated by cyanosis and recurrent right hydrothorax. A diagnostic pneumoperitoneum demonstrated that direct movement of ascites through a diaphragmatic defect was responsible for the hydrothoraces. Pulmonary function tests between episodes of hydrothorax showed severe arterial hypoxaemia, a 23% right-to-left shunt, and a reduction in the carbon monoxide transfer factor to less than half of the predicted value. Evidence of abnormal intrapulmonary arteriovenous communications was obtained by perfusion scanning. At necropsy the central tendon of the diaphragm showed numerous areas of thinning which were easily ruptured. Injection of the pulmonary arterial tree demonstrated precapillary arteriovenous anastomoses and pleural spider naevi. A morphometric analysis provided quantitative evidence of pulmonary vasodilatation limited to the intra-acinar arteries, consistent with the effect of a circulating vasodilator. The scintigraphic and pathological findings suggested that shunting had been greater in the right than the left lung. Examination of thin lung sections by light microscopy showed that the walls of small veins were thickened, and electron microscopy showed that this was due to a layer of collagen. The walls of capillaries were similarly thickened, which caused an approximately two-fold increase in the minimum blood-gas distance and contributed to the reduction in transfer factor.

Bronchoscopy in patients with haemoptysis and normal chest roentgenograms

We reviewed the records of 58 patients with haemoptysis and normal chest roentgenograms who underwent fibreoptic bronchoscopy. A diagnosis of malignancy was made in six patients at bronchoscopy. Three patients had bronchogenic squamous cell carcinoma, one a carcinoid tumour and two laryngeal carcinoma. Sputum for cytology was negative for malignant cells in all six patients. Follow-up data were available for the other 52 patients for an average period of 55.7 +/- 29.6 (SD) months. Two patients had a subsequent diagnosis of bronchogenic carcinoma at 2 and 6 years after initial evaluation. Three patients died from conditions not related to pulmonary malignancy and the remaining patients followed a benign course. Our patients come from a predominantly male, elderly population of cigarette smokers. Among such patients, we conclude that bronchoscopy is indicated in the evaluation of those with haemoptysis and a normal chest roentgenogram.

Pulmonary disease caused by Mycobacterium asiaticum

A 62-year-old male residing in Los Angeles, California, presented with a right upper lobe nodule associated with dry cough and weight loss. Mycobacterium asiaticum was isolated from sputum on two separate occasions. The patient was subsequently treated with four antituberculous drugs, with bacteriologic conversion. This is the first report of pulmonary disease caused by M. asiaticum in the United States. The bacteriologic, immunologic and clinical aspects are reviewed.

Gallium scanning and tomography in the preoperative evaluation of lung cancer

Discrepant reports on the utility of gallium scanning in the preoperative evaluation of patients with lung cancer prompted a prospective study of the test. The authors studied 47 patients with lung cancer who underwent preoperative gallium scanning and frontal tomography of the mediastinum. Both tests were found to be most accurate in predicting the presence of mediastinal metastases among patients with squamous cell carcinoma. Both tests may help direct surgical planning in patients with known squamous cell carcinoma of the lung. Cancer 58:341–343, 1986.

Survival in Patients with Superior Pulmonary Sulcus Tumors

We report our experience with 21 patients with superior sulcus tumors. Demographic features and survival were analyzed according to the stage of disease. Eleven patients had stage IIIA disease, 2 had stage IIIB disease and 8 had stage IV disease. Only 4 (19%) were amenable to surgery at the time of diagnosis and only 1 underwent combined preoperative radiotherapy and surgery. The majority of our patients were nonresectable at the time of diagnosis because of extensive disease or coexisting medical conditions. Overall, the probability of survival approached zero at 1 year. This poor survival is a reflection of nonresectability in the majority of our patients, which may be unique to our patient population.

Aspiration Lung Biopsy with Ultrathin Needles

Aspiration lung biopsy with ultrathin needles (gauge 24-25) was performed in 232 patients. A diagnosis was established with ultrathin needles in 134 of 164 patients with malignancy. Comparison of cytologic diagnosis and histologic diagnosis was made in 49 patients. There were no false-positive results, and histologic diagnosis was similar to cytologic diagnosis in 69% of cases. Only 8 of 55 patients with non-malignant conditions had the specific diagnosis established with ultrathin needle biopsy. Our data support the safety and efficacy of the procedure in patients with malignant disease. Although the yield in non-malignant conditions was low, the relative safety of the procedure justifies its use since patients may be spared of more invasive procedures.