Hartmut Zwick

Increased sensitization to aeroallergens in competitive swimmers

Chlorine is used to disinfect swimming pools or as a constituent of other disinfection reagents. Pulmonary diseases are occasionally observed after exposure to chlorine. In 14 competitive swimmers and in 14 matched control subjects, we searched for clinically manifest allergies, subclinical sensitization to aeroallergens, imbalance of the cellular immune system, and bronchial hyperresponsiveness. Conjunctival or respiratory symptoms were found in 11 swimmers (2 cases of conjunctivitis, 4 rhinitis, 2 rhinoconjunctivitis, 1 laryngitis, and 2 bronchitis) and in 3 controls. Sensitization to aeroallergens was confirmed in 9 swimmers by skin test and in 11 swimmers by radioallergosorbent test (RAST), compared to findings in 4 and 5 controls, respectively. An altered cellular immune system, (i.e., imbalance in T-cell system, B-cell system, or natural killer cells) was detected in 7 swimmers and only 2 controls. Bronchial hyperresponsiveness to methacholine was seen in 11 swimmers and 5 controls. This higher incidence of allergic diseases and subclinical sensitization to aeroallergens, disorders of the cellular immune system, and bronchial hyperresponsiveness in competitive swimmers compared with control subjects could be due to repeated exposure to chlorine in swimming pools.

Diagnostic sensitivity of different techniques in the diagnosis of lung tumors with the flexible fiberoptic bronchoscope. Comparison of brush biopsy, imprint cytology of forceps biopsy, and histology of forceps biopsy

Brush and forceps biopsies were done consecutively in 186 cases of pulmonary neoplasia with a flexible fiberoptic bronchoscope guided by x‐ray television fluoroscopy. Imprint and histologic sections were prepared from all forceps biopsy specimens. The three techniques were compared for their diagnostic sensitivity. As a result 84.9% of all imprints, 80.6% of brush biopsy specimens, and 62.9% of histologic sections were positive for malignancy. The sensitivity of brush biopsy specimens was independent of the location and morphology of the tumors, but the sensitivity of forceps biopsy specimens was lower in neoplasms unidentified by bronchoscopy. The sensitivity of the diagnostic accuracy when all three methods were used jointly was 97.3%, and the specificity was 100%. Agreement in the final morphologic tumor type was found in 130 of 150 cases (86.7%) by positive brush biopsy specimens, in 136 of 158 cases (86.1%) by positive imprint cytology, and in 104 of 117 cases (88.9%) by positive histology from forceps biopsy specimens. For routine bronchoscopy, all three methods should be used in combination to obtain the highest diagnostic yield.

Computerized Detection of Respiratory Events during Sleep from Rapid Increases in Oxyhemoglobin Saturation

A computerized search for rapid resaturation (RES)—defined as increases in oxyhemoglobin saturation (SaO2) of 3% or more within 10 s—was used to detect apneas and hypopneas during sleep by the episodes of compensatory hyperventilation following them. Results were compared to those from computerized search for desaturations (DESAT)—defined as decreases in SaO2 of 4% or more within 40 s—and to simultaneous polysomnography.We studied 30 patients with obstructive sleep apnea (OSA) with an apnea plus hypopnea index (AHI) of 30.8±6.9 (median ± SEM) and 23 habitual snorers (HSN) with an AHI of 7±1.5. Manual scoring of polysomnography revealed 7965 respiratory events (6192 apneas, 1773 hypopneas) in OSA patients and 940 events (411 apneas, 529 hypopneas) in the HSN group. In OSA patients, the computer found 96% of events by searching for RES and 87% by searching for DESAT. The percentage of computer-found events in OSA classified as true positive was 91% for RES and 97% for DESAT. In the HSN group, 83% of polysomnographically scored events were found by RES and 55% by DESAT, with 72% of RES and 84% of DESAT being true positive. The correlation of the number of computer-found RES with the number of events from polysomnography was better in OSA (r=0.862, p<0.0001) than in HSN (r=0.722, p<0.001). The same was true for DESAT (OSA: r=0.896, p<0.0001; HSN: r=0.637, p<0.01).In conclusion, computer-found rapid resaturations are more sensitive than desaturations for the detection of respiratory events during sleep from oximetry. Increased sensitivity of RES is accompanied by relatively well-preserved specificity.

Allergenic structures in cockroach hypersensitivity

The tissues from which cockroach allergens were derived were identified by use of serum IgE of five patients with allergic rhinitis and bronchial asthma as a result of hypersensitivity to German cockroach. RAST and skin test results demonstrated four of five patients to be positive to cockroach only, and one patient was tested positive to house dust mite as well. Allergen-specific IgE binding to German cockroach was investigated by cryostat sections by means of immunofluorescent test. In all patients with cockroach hypersensitivity, we found IgE bound to the gastrointestinal epithelium and contents of the intestinal tract. In four cases, IgE was also bound to the Malpighian vessels (equivalent in function to kidneys). In three cases, IgE was also bound to the ovarian cells. All cases revealed cytoplasmic staining.

Phrenic nerve function in type 1 diabetic patients with diaphragm weakness and peripheral neuropathy.

Phrenic nerve latency was studied in 14 male type 1 diabetic patients with impaired diaphragm function and in 14 healthy control subjects. The diabetics showed significantly decreased values regarding inspiratory vital capacity and forced volume in 1 s compared with the control subjects. All other lung function parameters were similar in both groups. Although motor and sensory nerve conduction studies provided evidence for peripheral neuropathy in all patients, phrenic nerve latencies turned out to be normal. These results rule out a neuropathic disorder of the phrenic nerve. Thus, impaired diaphragm function in type 1 diabetic patients is not caused by phrenic neuropathy.

No Effect of Naloxone on Ventilatory Response to Progressive Hypercapnia in IDDM Patients

The ventilatory response to hyperoxic progressive hypercapnia was examined by comparing 3 test groups: 7 diabetic patients with AN, 8 diabetic patients without AN, and 8 normal control subjects. In each group, a significant linear correlation was found between PaCO2 and VE. The slopes of the regression curves relating PaCO2 to VE were significantly steeper in the healthy control subjects and diabetic patients without AN than in those with AN (P < 0.01). We conclude that the ventilatory response to progressive hypercapnia is reduced in diabetic patients with AN. By analyzing the power spectrum and the amplitude behavior of the diaphragmatic EMG (calculated from the fc and RMS, respectively), we could exclude a disturbance of neural descending pathways and respiratory muscle dysfunction as possible causal mechanisms for the impaired ventilatory response to increasing CO2. By using lung function analysis, causal factors such as alterations in respiratory system mechanics also could be excluded. As diabetes is known to affect the endogenous opioid system, which, in turn, affects the ventilatory response to CO2, naloxone, as a specific opioid antagonist, was administered in all 3 test groups. Naloxone produced a significant increase of ventilatory response to hypercapnia in the healthy control subjects (P < 0.01), but produced no effect in either of the diabetic groups. We conclude that the ventilatory response to hypercapnia is impaired in diabetic patients with AN, that lung function alterations and diaphragmatic muscle dysfunction are not responsible for this impairment, and that endogenous opioids produce an effect on the response to CO2 in healthy subjects, but they have no effect on CO2 response in diabetic patients with or without AN. These results suggest that the central control of respiration is pathologically altered in diabetic patients with AN.

How much brushing is enough for the diagnosis of lung tumors

Background. Bronchoscopic investigations of lung tumors require high diagnostic accuracy. Sometimes the combination of brush biopsy with cytologic and histologic examination of forceps‐obtained biopsy specimens fails to diagnose tumors. Techniques with a minimum risk and low cost when repeated several times could increase the efficiency of tumor diagnosis and help to avoid rebronchoscopy.

Effects of the Sauna on Diffusing Capacity, Pulmonary Function and Cardiac Output in Healthy Subjects

The present study examined possible short-term effects of the heat stress during sauna bathing on gas exchange, especially in correlation with changes in cardiac output. The results obtained are as follows: (1) The heat stress of sauna bathing caused a slight but not significant increase in diffusion capacity (p = 0.239) and no change in other pulmonary function parameters. (2) Cardiac output and cardiac index increased slightly but not significantly (p = 0.2455 and p = 0.2719). We conclude that heat stress in sauna neither influences gas exchange nor does it cause a significant increase in cardiac output.

Bronchoalveolar lavage in rheumatoid arthritis and secondary Sjögren's syndrome.

Bronchoalveolar lavage (BAL) was performed to investigate pulmonary involvement in 39 patients with rheumatoid arthritis (RA) and in 7 patients with RA and secondary Sjögren’s syndrome, and compared to 12 healthy controls. Lymphocytosis (more than 15%) was seen in 25, and more than 3% neutrophil granulocytes in 8 of 39 patients with RA. Lymphocytosis and/or neutrophil granulocytosis was seen in both seropositive and seronegative patients irrespective of clinical or radiologic findings. Patients with RA with or without secondary Sjögren’s syndrome had increased DR + lymphocytes in BAL compared with peripheral blood. In 7 patients with secondary Sjögren’s syndrome an increased helper/suppressor cell index (OKT4 + / OKT8+: 7.65 ± 2.10) and increased natural killer cells (OKNK +: 27.3 ± 5.5%) were found, as compared to 39 other patients with RA (OKT4+ / OKT8+: 2.16 ± 0.33, p<0.05; OKNK+: 14.5 ± 2.3%, p<0.05).These BAL data are further evidence of frequent subclinical interstitial pulmonary involvement in RA with differences in the active autoimmune process from those in secondary Sjögren’s syndrome.

The effect of one year outpatient pulmonary rehabilitation on patients with COPD

SummaryBACKGROUND: The aim of our study was to determine the effect of one year of pulmonary rehabilitation (PR) on functional parameters and exacerbation rates in patients with chronic obstructive pulmonary disease (COPD). METHODS: A total of 100 patients were enrolled in a multidisciplinary PR program. PR included endurance, resistance and respiratory muscle training. We performed spiroergometry, a modified Bruce Test and measurements of upper and lower limb contractility as well as inspiratory muscle strength before, six and 12 months after beginning rehabilitation. Additionally, we assessed the quality of life and the number of exacerbations and exacerbation days one year before and after starting rehabilitation. RESULTS: 100 patients (42 female/58 male) with COPD (COPD IV – N = 36, COPD III – N = 42, COPD II – N = 22), a mean age of 60.5 ± 9.6 years, BMI 25.8 ± 6.0 attended a rehabilitation training program over a time period of one year. Spiroergometry (VO2max from 1.1 to 1.3 l/min, P < 0.05), modified Bruce Test (from 13 ± 7 Min to 18 ± 9 Min; P < 0.001), upper limb (from 39.9 ± 3 to 52.9 ± 8 kg; P < 0.001) and lower limb strength increased significantly (from 85.3 ± 45 to 131.5 ± 57 kg; P < 0.001). The maximal inspiratory pressure rose from 81,1 mbar to 108,8 mbar (p < 0.001). There was no improvement in FEV1 or FEV1/FVC but Saint Georges Respiratory Questionnaire (total score) improved from 37.2 ± 3.6 to 26.5 ± 2.8; P < 0.001. The same was true for exacerbation rates (they dropped from 2.8 to 0.8; P = 0.006) and the number of hospitalization days (from 27.3 to 3.3, P < 0.001). CONCLUSIONS: One year of outpatient pulmonary rehabilitation is an effective intervention leading to a significant improvement in exercise tolerance and quality of life in patients with COPD also reducing COPD exacerbation rates and hospitalizations.ZusammenfassungHINTERGRUND: Ziel unserer Studie war es, den Effekt von einem Jahr ambulanter wohnortnaher Rehabilitation auf funktionelle Parameter sowie auf die Lebensqualität und Exazerbationsrate bei Patienten mit COPD zu untersuchen. METHODIK: Wir inkludierten 100 Patienten in ein multidisziplinäres Rehabilitationsprogramm, welches sowohl Ausdauer-, Kraft- und inspiratorisches Atemmuskeltraining beinhaltet. Wir führten folgende Messungen vor der Rehabilitation sowie nach sechs und 12 Monaten durch: Spiroergometrie, modifizierter Bruce Test, Kraft der Arme und Beine sowie inspiratorische Atemmuskelkraft. Zusätzlich wurde der Saint Georges Respiratory Questionnaire und die Exazerbationstage ein Jahr vor sowie während der Rehabilitation erhoben. ERGEBNISSE: 100 Patienten (42 f/58 m) mit COPD (COPD IV – N = 36, COPD III – N = 42, COPD II – N = 22), einem mittleren Alter von 60,5 ± 9,6 Jahren, einem BMI von 25,8 ± 6,0 begannen ein pneumologisches Rehabilitationsprogramm über einen Zeitraum von einem Jahr. Die Spiroergometrie (VO2max von 1,1 auf 1,3 l/Min, P < 0.05), der modifizierte Bruce Test (von 13 ± 7 Min auf 18 ± 9 Min; P < 0.001), die Kraft der Arme (von 39,9 ± 3 auf 52,9 ± 8 kg; P < 0.001) und Beine verbesserten sich (von 85,3 ± 45 auf 131,5 ± 57 kg; P < 0.001). Der Maximal inspiratorische Druck stieg von 81,1 auf 108,8 mbar (P < 0.0001). Es kam zu keinen Veränderungen in der FEV1 oder FEV1/FVC, jedoch der Saint Georges Respiratory Questionnaire (Gesamtscore) verbesserte sich von 37,2 ± 3,6 auf 26,5 ± 2,8; P < 0.001. Auch kam es zu einer Reduktion der Exazerbationsraten von 2,8 im Jahr vor der Rehabilitation auf 0,8; P = 0.006) sowie der Hospitalisationstage (von 27,3 auf 3,3, P < 0.001). FOLGERUNGEN: Ein Jahr ambulanter pneumologischer Rehabilitation führt zu einer deutlichen Verbesserung der körperlichen Leistungsfähigkeit und der gesundheitsbezogenen Lebensqualität, weiters können die Anzahl der Exazerbationen sowie die Hospitalisationstage reduziert werden.BACKGROUND The aim of our study was to determine the effect of one year of pulmonary rehabilitation (PR) on functional parameters and exacerbation rates in patients with chronic obstructive pulmonary disease (COPD). METHODS A total of 100 patients were enrolled in a multidisciplinary PR program. PR included endurance, resistance and respiratory muscle training. We performed spiroergometry, a modified Bruce Test and measurements of upper and lower limb contractility as well as inspiratory muscle strength before, six and 12 months after beginning rehabilitation. Additionally, we assessed the quality of life and the number of exacerbations and exacerbation days one year before and after starting rehabilitation. RESULTS 100 patients (42 female/58 male) with COPD (COPD IV-N=36, COPD III-N=42, COPD II-N=22), a mean age of 60.5+/-9.6 years, BMI 25.8+/-6.0 attended a rehabilitation training program over a time period of one year. Spiroergometry (VO2max from 1.1 to 1.3 l/min, P<0.05), modified Bruce Test (from 13+/-7 Min to 18+/-9 Min; P<0.001), upper limb (from 39.9+/-3 to 52.9+/-8 kg; P<0.001) and lower limb strength increased significantly (from 85.3+/-45 to 131.5+/-57 kg; P<0.001). The maximal inspiratory pressure rose from 81.1 mbar to 108.8 mbar (p<0.001). There was no improvement in FEV1 or FEV1/FVC but Saint Georges Respiratory Questionnaire (total score) improved from 37.2+/-3.6 to 26.5+/-2.8; P<0.001. The same was true for exacerbation rates (they dropped from 2.8 to 0.8; P=0.006) and the number of hospitalization days (from 27.3 to 3.3, P<0.001). CONCLUSIONS One year of outpatient pulmonary rehabilitation is an effective intervention leading to a significant improvement in exercise tolerance and quality of life in patients with COPD also reducing COPD exacerbation rates and hospitalizations.