G K Crompton

Comparison of salbutamol given intravenously and by intermittent positive-pressure breathing in life-threatening asthma.

A double-blind crossover trial was carried out during 22 episodes of life-threatening asthma in 19 patients to compare salbutamol given as a 500 microgram intravenous injection and as a 0 . 5% solution administered by intermittent positive-pressure breathing (IPPB) for three minutes. Relief of pulsus paradoxus was significantly better after IPPB than the intravenous treatment. Both treatments significantly improved the peak expiratory flow rate. Salbutamol given intravenously produced a mean increase in heart rate of over 20 beats/min five minutes after treatment compared with the relief of tachycardia that occurred after administration by IPPB. Four patients had noticeable cardiovascular side effects after salbutamol given intravenously, but no such effects were noticed after administration by IPPB. Two patients withdrawn shortly after entry into the trial because of a worsening clinical condition had received intravenous salbutamol. It is concluded that salbutamol given by IPPB is better than that given by slow intravenous injection in severe acute asthma.

Substitution of Beclomethasone Aerosol for Oral Prednisolone in the Treatment of Chronic Asthma

In a double-blind study 10 patients with chronic asthma received beclomethasone dipropionate 400 μg daily in a Freon propellant from a pressurized dispenser, and 10 patients received the Freon propellant alone. At the start of the trial each patient was receiving long-term maintenance treatment with oral prednisolone in a dose of 7·5 to 15 mg daily. The daily dose of prednisolone was reduced by 1 mg every four weeks and the patients progress followed by regular clinical assessment and studies of pituitary-adrenal function. The trial was continued until the dose of prednisolone was reduced to zero or until asthmatic symptoms increased to an unacceptable level. In the 10 patients who received beclomethasone the mean maintenance dose of oral prednisolone was reduced by 5·6 mg/day but in only two cases could this drug be withdrawn completely. In the placebo group the mean reduction in dose was only 1·3 mg, thus there was a significant difference between the two groups (P <0·01). Studies of pituitary-adrenal function showed that a normal adrenal response to tetracosactrin stimulation returned only in the two patients from whom prednisolone was withdrawn. Hence the addition of beclomethasone dipropionate by inhalation to systemic corticosteroid therapy allows useful reductions to be made in the oral maintenance doses of corticosteroid. Reductions must be made with caution since there is wide individual variation in response to beclomethasone and in only a minority of patients can oral treatment by completely withdrawn.

Treatment of bronchopulmonary aspergillosis with clotrimazole.

Summary Four patients with bronchopulmonary aspergillosis were treated with clotrimazole in a dose of 100 mg/kg/day. To assess the effect of treatment on the amount of fungus present in sputum, the numbers of colonies of Aspergillus fumigatus cultured from 24-hour specimens of sputum, collected before and at regular intervals during clotrimazole administration were recorded. Chest radiographs and tomographs were examined at fortnightly intervals and serum levels of clotrimazole were measured. One patient was treated with clotrimazole for 3 months, 2 for 2 months and in 1 treatment had to be withdrawn after a few days because of unwanted effects. There was no mycological or radiographic evidence of improvement in any patient. Serum levels of clotrimazole were found to be considerably lower than the minimum inhibitory concentration of the organisms in all patients treated, and serum levels estimated after a single dose of clotrimazole given to 4 patients not suffering from aspergillosis were also low. No evidence of haematological, liver, renal or adrenal dysfunction was observed.

Phase II trial of vindesine and VP16-213 in the palliation of poor-prognosis patients and elderly patients with small cell lung cancer

SummaryForty-three previously untreated patients, all of whom had poor-prognosis small cell lung cancer and/or were >65 years old, received treatment with vindesine and VP16-213. Thirteen patients had limited disease and 30 extensive disease. Response rates (CR+PR) of 86% (CR 29%) and 66% (CR 17%) were seen in patients with limited and extensive disease, respectively. Time to relapse was short in those responding (4–4.5 months), and most responders required additional treatments. The overall toxicity was minimal and patient compliance was high. This combination is useful for the palliative treatment of small cell lung cancer when aggressive chemotherapy is inappropriate.

Pneumocystis carinii in bronchoalveolar lavage fluid and bronchial washings.

Antibodies to Pneumocystis carinii develop in early childhood,1 although no associated illness has been identified. The classic concept in that P carinii pneumonia in immunocompromised patients represents a reactivation of dormant childhood infection. Studies with DNA amplification, however, have failed to detect pneumocystis in sputum2 or specimens of lung tissue taken at necropsy3 from immunocompetent patients. Reinfection rather than reactivation may therefore be more relevant. To see whether P carinii exists as a commensal organism of the lower respiratory tract we examined bronchoalveolar lavage fluid and bronchial washings in apparently immunocompetent patients undergoing routine diagnostic (or research) bronchoscopy by using an immunofluorescent antibody test. We studied 220 patients with various clinical diagnoses (table). Patients were considered to have no active disease if investigations, including bronchoscopy, failed to show any lung disease. Patients with …

NEBULIZED SALBUTAMOL IN LIFE-THREATENING ASTHMA: IS IPPB NECESSARY?

A double-blind crossover trial compared equal doses of nebulized salbutamol delivered with and without intermittent positive pressure breathing (IPPB) in 20 patients admitted to hospital with life-threatening asthma. No significant differences were observed between the two forms of treatment. It was concluded that the use of IPPB to administer nebulized salbutamol in oxygen had no advantage over passive inhalation in the initial treatment of patients with severe acute asthma.

A comparative study of two doses of salbutamol nebulized at 4 and 8 litres per minute in patients with chronic asthma

A comparative study of the clinical response to salbutamol nebulized by an Inspiron Mini-Neb using flow rates of 4 and 8 litres/min is described. Forty patients with chronic asthma were given doses of approximately 1 mg and 5 mg of salbutamol using flow rates of either 4 or 8 litres/min. The two flow rates and the two dosages produced similar increases in FEV1 and FVC and similar changes in pulse rate. These results demonstrate that flow rates of 4 litres/min, such as can be produced by a domestic oxygen cylinder, and doses of 1 mg salbutamol are effective in the treatment of patients with chronic reversible airflow obstruction. While we do not advocate the general use of oxygen cylinders to drive nebulizers, our study shows that this form of administration produces a bronchodilator response similar to that using a flow rate of 8 litres/min.

Comparison of fenoterol and terbutaline administered by intermittent positive pressure breathing.

The bronchodilator properties and side-effects of three doses of fenoterol (0.5 mg, 1 mg and 2 mg) and terbutaline (2.5 mg, 5 mg and 10 mg) were assessed in 12 patients with stable chronic asthma. The drugs were administered by intermittent positive pressure breathing (IPPB) in 40% oxygen via a Bennett ventilator. No differences likely to be of clinical significance were found between the effects of the three different dose levels of fenoterol and terbutaline, although terbutaline had a significantly greater duration of action. It is concluded that fenoterol 2 mg and terbutaline 10 mg can be administered by IPPB in 40% oxygen for the treatment of asthma.

UNUSUAL PULMONARY REACTIONS TO OILY PROPYLIODONE (DIONOSIL) IN BRONCHOGRAPHY

Severe reactions to oily propyliodone are rare. Side-effects are usually mild and self-limiting. Three cases are reported of early pulmonary reactions, the cause of which may be a chemical pneumonitis or possibly an allergic response to one of the components of the contrast medium. There was a good response to corticosteroid therapy in all three patients.

Artificial ventilation for neurological disease: retrospective analysis 1972-81.

During the 10 year period 1972-81, 39 patients with neurological disorders referred to a respiratory unit required artificial ventilation, seven on two occasions. The decision to undertake ventilation was usually made on clinical grounds because of deteriorating respiratory effort, ineffective cough, or inability to swallow. Arterial blood gas studies were of limited value in assessing the need for ventilation. The most frequent complication was bronchopulmonary infection which occurred in almost every patient, Staphylococcus pyogenes, Pseudomonas pyocyanea, and coliforms being the organisms most commonly isolated. In contrast, serious complications of tracheostomy and pulmonary thromboembolism occurred infrequently. There were 10 deaths among the 39 patients ventilated on 46 occasions; six were directly attributable to the neurological disease itself but four resulted from complications of artificial ventilation.