Gennaro M. Tisi

Increased high density lipoprotein cholesterol in obstructive pulmonary disease (predominant emphysematous type)

Abstract Since increased levels of high density lipoprotein-cholesterol (HDL-C) seem to be protective against coronary heart disease, there is increasing interest in mechanisms whereby HDL-C levels can be increased. Recent studies suggest that exercise can elevate HDL-C. Patients with chronic obstructive pulmonary disease (COPD), who are usually considered as leading sedentary lifestyles, have an increased work of breathing and their respiratory muscles may be considered to be under a chronic exercise load. Twenty-nine male patients with COPD were selected on the basis of their clinicalphysiologic data, which suggested a predominant emphysematous component of their disease. Clinical features and pulmonary function studies characterized the patients as having relatively pure emphysema (i.e., pink puffers): weight 98% ± 4% (SE) of ideal body weight; absence of cough and sputum; no evidence of cor pulmonale; overinflation in each patient by chest roentgenogram and either curvilinear lines or bullae in 25 of 29 patients; arterial oxygen tension, 62.7 ± 1.4 mm Hg; arterial carbon dioxide tension, 39.8 ± 1.3 mm Hg; severely reduced expiratory flow rate for the midportion of the forced expiratory curve, 0.27 ± 0.02 LPS; overinflation with a residual volume to total lung capacity ratio of 67% ± 1.5% (normal 19) and a coefficient of retraction of 1.9 ± 0.27 cm H20/liter (normal range 2.5–8.5); minute ventilation (VE) of 10.8 ± .24 liters (normal 6.37 ± 0.9); oxygen consumption (Vo 2 ) of 251 ± 9 ml (normal 230 ± 30); ventilatory equivalent (V E/Vo 2 ), 44 ± 1.9 (normal 20–30). Levels of HDL-C were 72 ± 4 mg/dl vs. 54 ± 3 mg/dl for controls matched for age, obesity index, alcoholic intake, smoking history, and race. The HDL-C levels in the patient group were similar to those reported by other workers for long distance runners, and cross country skiers. We suggest these data provide another link between increased levels of HDL-C and exercise.

Extending Resectability for Carcinoma of the Lung in Patients with Impaired Pulmonary Function

Abstract A total of 49 consecutive patients who had resection for carcinoma of the lung is reported. Twenty-two of the patients had marginal pulmonary function, forced expiratory flow rate less than 1.0 liter per second, and forced vital capacity in the first second less than 70%. Of the total group, 23 were more than 60 years old, and 13 of these had marginal pulmonary function. Thirteen patients had pneumonectomy, with no hospital mortality; 30 had lobectomy, with 3 hospital mortalities; and 6 had wedge resection, with 1 hospital mortality. No patients had pulmonary insufficiency in the postoperative period or died of pulmonary insufficiency. The selection of patients was based on a combination of data on flow rates, vital capacity, and regional ventilation perfusion scans. The good results may be due to the fact that despite major obstructive disease of the airway, vital capacity was preserved (92 ± 16% of predicted). Intraoperative use of the Robertshaw tube, preservation of as much lung as possible, and use of local analgesia during the postoperative period were apparent contributors to the low mortality and the absence of pulmonary insufficiency.

Preoperative identification and evaluation of the patient with lung disease

Preoperative pulmonary function evaluation begins with the bedside, clinical identification of the presence of significant lung disease. Once a patient is so identified, preoperative pulmonary-function studies are indicated. The optimal screening studies for most patients are spirometry and arterial blood gas analysis. Patients who are identified as having marginal function by screening techniques should be studied further by more specialized studies, including radioisotopic evaluation of regional lung function. If a patient is identified as an operative candidate, but one who has increased risk of postoperative morbidity, prophylactic measures should be instituted to reduce postoperative complications. The essence of such measures is increased care preoperatively, intraoperatively, and postoperatively. The use of preoperative evaluation of pulmonary function presents a different magnitude of problem in defining the risk of morbidity in contrast to that of mortality. Available data provide a firm basis for the identification of the patient at increased risk of morbidity. After 23 years and dozens of spirometric studies involving thousands of patients, it is apparent that there is no spirometric number, percentage, or category that will absolutely separate the operable from the inoperable patient. There are estimates of risk--guidelines, to be sure--but no absolutes. The patient whose lung function would have been considered to prohibit lung resection in the 1950s has been successfully operated on in the 1980s. In dealing with the risk of mortality, the physician should always bear in mind that, although statistics apply to groups, they often do not apply to individual patients.

Correlation of lung photoscans with pulmonary angiography in pulmonary embolism

Abstract Ten patients with clinical-laboratory evidence suggesting extensive acute or chronic pulmonary thromoboembolism were studied by pulmonary photoscan and by utilizing radiolabeled macroaggregates of human serum albumin (R-MAA) and by angiographic technics. A high degree of correlation between the inactive areas of the radioscan and the nonperfused areas of the angiogram was noted. The radioscan accurately reflected the pattern of arteriolarcapillary blood flow, whereas the angiogram provided precise information regarding the pulmonary vascular anatomy. The two procedures should be considered complementary rather than competitive. Lung radioscanning was found to offer a readily available, safe, rapid and reliable screening technic for definition of nonperfused pulmonary areas. Problems in radioscan interpretation, including “false positives,” lack of anatomic precision and limitations of resolution are discussed. Such problems underscore the basic tenet that accurate evaluation of the radioscan requires that it be viewed in proper clinical context.

“Alveolarization” of Tantalum Powder in Experimental Bronchography and the Clearance of Inhaled Particles from the Lung

Bronchography employing tantalum powder insufflation was performed in healthy dogs, dogs with pulmonary infections, and dogs in which increased pulmonary secretions were simulated by carboxymethylcellulose solutions. Aspiration of tantalum-laden secretions into the peripheral airways was observed. Serial radiographs showed little change after 48 hours. Upon reaching the alveoli, metal particles were phagocytized and incorporated into peribronchiolar dust macules or thickened septa; some were later transported to the hilar lymph nodes. No cytotoxic reaction was observed. Prolonged pulmonary opacification may result from the use of tantalum powder in the lower airways.

COLLAPSE OF LEFT LUNG INDUCED BY ARTIFICIAL AIRWAY

Abstract In eighteen months ten cases of collapse of the left lung induced by an artificial airway were observed in a single hospital. Onset of this complication may declare itself dramatically by tachypnœa, hypotension, and cyanosis; but symptoms may be absent. Accordingly all patients in whom a tracheostomy has been instituted or an endotracheal tube has been inserted should be repeatedly examined. Withdrawal of the artificial airway from the right main-stem bronchus, in which it occludes the left main-stem bronchus, leads to prompt recovery.

Intravenous administration of alpha-1-proteinase inhibitor in patients of PiZ and PiM phenotype

Nine patients with moderate pulmonary emphysema, six of PiZ phenotype and three of PiM phenotype, have received a single intravenous infusion of alpha-1-proteinase inhibitor (human) (A1PI), in a dose of 60 mg/kg over a 30-minute period. They also received a tracer dose (300 microCi) of 131I-labeled A1PI. No active or passive immunization against hepatitis was given. No acute toxicity was observed. Compared with baseline data, significant elevations of serum A1PI (measured both antigenically and as anti-elastase activity) occurred, with a serum half-life approximating 110 hours. Bronchoalveolar lavage fluid, obtained 48 hours after infusion, reflected a significant increase in A1PI concentration versus baseline bronchoalveolar lavage fluid values. Serial gamma camera images of the lungs confirmed persistence of enhanced lung radioactivity for several days. Urinary desmosine excretion did not change following A1PI infusion. During the period of follow-up thus far, no patient has had chronic toxicity, results of liver function tests have been stable, and there has been no development of hepatitis B antigen or antibodies to hepatitis B surface or core antigens.

Intravenous administration of alpha-1-proteinase inhibitor in patients of PiZ and PiM phenotype: Preliminary report

Abstract Nine patients with moderate pulmonary emphysema, six of P i Z phenotype and three of P i M phenotype, have received a single intravenous infusion of alpha-1-proteinase inhibitor (human) (A1PI), in a dose of 60 mg/kg over a 30-minute period. They also received a tracer dose (300 μCi) of 131 I-labeled A1PI. No active or passive immunization against hepatitis was given. No acute toxicity was observed. Compared with baseline data, significant elevations of serum A1PI (measured both antigenically and as anti-elastase activity) occurred, with a serum half-life approximating 110 hours. Bronchoalveolar lavage fluid, obtained 48 hours after infusion, reflected a significant increase in A1PI concentration versus baseline bronchoalveolar lavage fluid values. Serial gamma camera images of the lungs confirmed persistence of enhanced lung radioactivity for several days. Urinary desmosine excretion did not change following A1PI infusion. During the period of follow-up thus far, no patient has had chronic toxicity, results of liver function tests have been stable, and there has been no development of hepatitis B antigen or antibodies to hepatitis B surface or core antigens.