M. Henry Williams

The adequacy of inhalation of aerosol from canister nebulizers

Thirty patients hospitalized with asthma who had been taking aerosol bronchodilators from canister nebulizers were evaluated for their aerosol inhalation technique. Fourteen patients (47 percent) used an incorrect technique. The most frequent mistake was to inhale first, then to actuate the canister and breathhold. These patients were taught the correct technique. Some learned it easily but others had difficulty. With a teaching aid, incorporating a horn which is actuated by inspiration, all 14 patients learned to inhale the aerosol correctly. When retested five of the 10 patients had reverted to the old incorrect technique and required another lesson. Physicians who prescribe aerosol medication from a canister nebulizer should evaluate each patient for the aerosol inhalation technique. Those who inhale incorrectly should be taught repeatedly until they learn the correct technique and retain it. The teaching aid, utilizing an audio signal, is helpful in this training.

Effect of odors in asthma

Many patients complain that some odors worsen their asthma. Perfume and cologne are two of the most frequently mentioned offenders. Four patients with a history of worsening of asthma on exposure to cologne underwent challenge with a cologne, and their pulmonary function was tested before, during, and after the exposure. Forced expiratory volume in one second declined 18 to 58 percent below the baseline period during the 10-minute exposure and gradually increased in the next 20 minutes. Saline placebo pretreatment did not affect the response to subsequent challenge. Single-blind pretreatment with metaproterenol and atropine prevented decline in one-second forced expiratory volume in three of four patients and blunted the response in the other. Cromolyn sodium prevented decline in one of four, and occlusion of nostrils prevented decline in one of three. A survey of 60 asthmatic patients revealed a history of respiratory symptoms in 57 on exposure to one or more common odors. Odors are an important cause of worsening of asthma.

Lactic acidosis in severe asthma

Twelve patients with severe asthma in whom lactic acidosis developed are presented. All had an arterial blood pH level lower than that expected for the measured partial pressure of arterial carbon dioxide, all had an abnormally large anion gap, and the blood lactate level exceeded 2.8 mmol/liter. Respiratory acidosis subsequently developed in eight patients, and six required intubation. Lactic acidosis can develop in patients with severe asthma. Such patients are in danger of the development of respiratory failure and must be treated vigorously and observed closely.

Cardiac Arrhythmias Resulting from Tracheal Suctioning

Abstract Seventeen patients with lung disease were monitored with an electrocardiogram during tracheal suctioning after they had breathed both air and 100% oxygen. Eight of them had a tracheostomy,...

Response to corticosteroids in chronic bronchitis.

Corticosteroid drugs are often employed in the treatment of patients with chronic bronchitis. Although some patients respond favorably to such therapy, the characteristics of such patients are not known. Twenty-four patients with chronic bronchitis were treated with prednisone 30 mg daily or placebo for one week each in a double-blind crossover study. The following were monitored before and after each treatment period: physical examination, symptoms, peripheral blood eosinophil count, sputum cell exmination, forced vital capacity (FVC), before and after isoproterenol aerosol. Seven of 24 patients had an FEV1 increase greater than 30% of the control value on prednisone but not on placebo. Blood eosinophil count was elevated (greater than or equal to 350/mm(3)) in 7 patients; 2 of these 7 improved on steroid. Sputum cell examination revealed preponderance of eosinophils in 1, and occasional clumps of eosinophils in 8. Seven of these 9 responded to steroid. Sputum but not blood eosinophilia is a good predictor of a favorable response to steroid therapy.

The effect of sequential inhalations of metaproterenol aerosol in asthma

In 19 asthmatic patients, three inhalations of metaproterenol (0.65 mg per puff) followed by placebo at 10 and 20 min were compared with one inhalation of the drug every 10 min for the same total of three doses. Metaproterenol 0.65 mg produced just as much increase of 1-sec forced expiratory volume (FEV1) as did the much larger dose (1.95 mg), but each subsequent inhalation of the drug produced further, significant increase of FEV1 suggesting better penetration of the bronchidilator aerosol after some bronchodilation had been achieved. After completion of treatment, the FEV1 was significantly higher when the drug was given sequentially rather than all at once. These data have important implications with respect to the utilization of bronchodilator aerosols in the treatment of asthma and indicate the unsuitability of sequential inhalation for study of dose response of these agents.

Methadone-Induced Pulmonary Edema

Abstract Two healthy young adults without previous history of drug use were admitted to the Bronx Municipal Hospital Center after methadone overdose resulted in coma, cyanosis, hypoventilation and ...

Effect of bronchodilator therapy administered by canister versus jet nebulizer

Bronchodilator efficacy of metaproterenol sulfate aerosol therapy delivered either by canister or jet nebulizer was compared in 25 patients, 13 with severe asthma and 12 with COPD. Treatment was carried out in double-blind crossover fashion on 2 days and consisted of either metaproterenol sulfate solution 15 mg in 2.3 ml administered from a jet nebulizer or three puffs of metered-dose metaproterenol sulfate (total 1.95 mg) inhaled sequentially. FVC and FEV1 were monitored before and after therapy for 2 hr. In 13 asthmatic patients, FEV1 increased from a baseline mean of 0.83 L to 1.57 L at 2 hr after jet nebulizer therapy and increased from 0.84 L to 1.52 L after canister therapy. In 12 patients with COPD, FEV1 increased from 0.58 L to 0.78 L after jet nebulizer therapy and from 0.57 L to 0.76 L after canister therapy. FVC also increased similarly after each form of therapy. The two types of aerosol therapy were equally effective and were without side effects. Canister therapy has the advantage over jet nebulizer therapy by being convenient and cheaper.

PULSUS PARADOXUS IN ASTHMA

Ninety-three patients with asthma were examined on 308 occasions for systolic fluctuation of blood-pressure during quiet breathing. Pulsus paradoxus (fluctuation of 10 mm Hg or greater) was present on 110 occasions. A pulses paradoxus was associated with greater airflow obstruction (average peak expiratory flow-rate 33.6% of the predicted) than an absent pulsus paradoxus which was associated with a peak expiratory flow-rate of 55.4%. However, pulsus paradoxus was often present in mild obstruction and absent in severe obstruction. In six patients the effect of changing respiratory pattern on systolic fluctuation was studied. Systolic fluctuation was directly related to the inspiratory flow-rate. This is probably one of the major reasons why association of airflow obstruction with pulsus paradoxus is not constant.

Course of pulmonary sarcoidosis with and without corticosteriod therapy as determined by pulmonary function studies

Abstract Serial pulmonary function studies over a six year period in forty-three patients with pulmonary sarcoidosis are reported. Twenty patients received corticosteroid therapy at some time during the course of their illness. The single breath carbon monoxide diffusing capacity (Dco), the vital capacity (Vc), and the maximal mid-expiratory flow rate (MMF) were the principal indices followed. On the basis of the single breath diffusing capacity for carbon monoxide, the patients were divided into two groups: those with mild impairment of pulmonary function (Dco greater than 65 per cent of predicted normal), and those with severe impairment of pulmonary function (Dco 65 per cent of predicted normal or less). Pulmonary function improved spontaneously in only a small percentage of patients with sarcoidosis. Indeed, the diffusing capacity fell in some patients despite complete clearing on the x-ray film of the chest. Corticosteroids produced improvement in all but one of the patients with severe impairment of pulmonary function, but with the cessation of therapy reversion to the previous status occurred in most. Corticosteroid therapy had no consistent beneficial effect on patients in whom pulmonary function was only mildly impaired initially.