Randolph J. Lipchik

Pulmonary function changes in long-term survivors of bone marrow transplantation

PURPOSE This study was undertaken to evaluate long-term pulmonary function changes in patients undergoing bone marrow transplantation (BMT), to assess their clinical significance, and to identify factors influencing these changes. METHODS AND MATERIALS Pulmonary function tests (PFT) were evaluated before and after BMT in 111 adult patients undergoing BMT between 1985 and 1991. Forced expiratory volume at 1 s (FEV1), forced vital capacity (FVC), diffusing capacity (DLCO), and total lung capacity (TLC) were evaluated. One hundred and three patients (92.8%) received total body irradiation (TBI) to a total dose of 14 Gy in nine equal fractions. The lung dose was restricted to < 6.5 Gy in 95% of patients with partial transmission lung shielding. Seventy-eight percent of patients had acute graft-versus-host disease (aGVHD), 69% chronic graft-vs.-host disease (cGVHD), and 63% posttransplant pulmonary infection. Effects of GVHD, TBI, radiation dose to the lungs, dose rate of TBI, posttransplant pulmonary infection, Busulfan use for conditioning, age, and history of smoking were evaluated for their influence on pulmonary function. RESULTS Posttransplant FEV1, FVC, and TLC were lower than pretransplant values (p < 0.05) at 6 months and 1 year posttransplant with subsequent recovery. DLCO was significantly lower at all posttransplant intervals. FEV1 did not fall significantly in patients without acute or chronic GVHD and recovered earlier than in patients without posttransplant pulmonary infection. Recovery of FVC, TLC, and DLCO was also delayed in patients with acute and chronic GVHD and posttransplant pulmonary infection. Multiple regression analysis revealed an association between a higher radiation dose to the lungs, and decreased FVC at 2 years (p = 0.01). Progressive obstructive pulmonary disease was not observed. CONCLUSION An initial decline in PFTs with subsequent recovery was observed. Factors associated with delayed recovery and incomplete recovery of PFTs were GVHD, posttransplant pulmonary infection, and higher radiation dose to the lungs. The conditioning regimen used at Medical College of Wisconsin, including relatively high TBI doses with partial transmission pulmonary shielding, appears to be well tolerated by the lungs in long-term survivors. No progressive decline in PFTs or symptomatic decline in pulmonary function was observed during the time interval studied.

Self-selected walking velocity for functional ambulation in patients with end-stage emphysema.

PURPOSE Considerable attention has been given to ambulation and dyspnea in the population with chronic obstructive pulmonary disease; however, previous studies leave the question of what constitutes functional ambulation in this population unanswered. This article examines ambulation for functional independence in the community for patients with-end-stage emphysema based on their self-selected walking velocity (SSWV) during a 6-minute walk (6 MW) and a timed get up and go (GUG) test. METHODS Fifty-nine patients (28 women, 31 men; mean age of 65.1 +/- 7.2 years) referred for lung transplantation or lung volume reduction surgery (mean forced expiratory volume in 1 second [FEV1] of 0.60 +/- 0.20 L; mean FEV1 as percent of predicted [FEV1%] of 22.7 +/- 8.7%) each had a 6 MW and GUG test performed on the same day. Calculations for SSWV and estimated energy expenditure were determined using the horizontal walking formula by the American College of Sports Medicine. RESULTS No statistically significant gender differences were identified for distance walked (235.1 +/- 92.0 m), rest time taken (33.2 +/- 58.5 seconds), actual walk time (5.5 +/- 1.0 minutes), or SSWV (42.2 +/- 13.9 m/min or 1.6 +/- 0.5 miles per hour) during the 6 MW. Men tended to walk farther and faster but rested more. The SSWV during the GUG test was similar (mean 41.8 +/- 10.9 m/min or 1.6 +/- 0.4 miles per hour) to the SSWV during the 6 MW. Estimated energy expenditure was approximately 1.6 to 3.4 metabolic equivalents (METS; mean 2.3 +/- 0.5 METS). CONCLUSION The literature defines independent community ambulation as the ability to walk at least 332 m at a near-normal velocity of approximately 80 m/min. This study population was significantly impaired for both distance and the velocity required to ambulate independently in the community. Documentation of both rest time and walk time taken during a 6 MW test will enable SSWV to be calculated and interpreted as it relates to independent community ambulation.

Systemic lupus-induced diffuse alveolar hemorrhage treated with extracorporeal membrane oxygenation: a case report and review of the literature.

Objectives: We report the case of a 28-year-old patient with systemic lupus erythematosus (SLE) with rapid onset of dyspnea and hemoptysis found to have diffuse alveolar hemorrhage (DAH) with refractory hypoxemia successfully treated with venovenous extracorporeal membrane oxygenation (ECMO). The discussion includes clinical presentation, diagnosis, management, outcome, and a review of the available adult literature on the use of ECMO in patients with DAH. Design: Case report. Setting: Froedtert Hospital and the Medical College of Wisconsin. Data Sources: Data were collected from the patient’s electronic medical record and the hospital radiology database. Conclusions: Diffuse alveolar hemorrhage secondary to SLE is quite rare. The adult literature on the utilization of ECMO for DAH is limited mostly to antineutrophil cytoplasmic antibody (ANCA)-associated alveolar hemorrhage and a few reports of nonvasculitis DAH. Bleeding has been a contraindication to ECMO due to the need for systemic anticoagulation. Our case, along with a review of the literature, indicates that ECMO with anticoagulation can be safely utilized in patients with DAH. To our knowledge, this is the first reported adult case of DAH due to SLE successfully treated with ECMO.

Functional and oximetric assessment of patients after lung reduction surgery.

OBJECTIVE The goal of this study was to clarify the issue of functional oxygen requirement by regimented exercise oximetry in patients undergoing lung reduction surgery. METHODS Thirty-seven patients underwent lung reduction surgery and were followed up for at least 3 months. Patients routinely completed a 6-week program of cardiopulmonary rehabilitation. Preoperative and postoperative spirometry, dyspnea scores, 6-minute walk distances, respiratory mechanics, and exercise oximetry were recorded. RESULTS After the operation, patients had a 37% increase in forced vital capacity and a 59% increase in forced expiratory volume in 1 second. Six-minute walk distance increased from 913 +/- 310 feet before the lung reduction operation to 1202 +/- 274 feet 6 months after the operation (p < 0.001). Maximal inspiratory and expiratory pressures were significantly increased in 16 patients after lung reduction surgery. Perceived dyspnea was significantly improved. Exercise pulse oximetry demonstrated that 83% of patients met American Thoracic Society criteria for supplemental oxygen use before lung reduction surgery. After the operation, 70% of patients continued to meet American Thoracic Society criteria for supplemental oxygen use. Notably, 10 patients with exertional desaturation while breathing room air discontinued supplemental oxygen use because of a reduction in dyspnea. CONCLUSIONS These findings demonstrate significant subjective and functional improvements related to lung reduction surgery. Exercise-induced hypoxia was not reversed by lung reduction surgery. Discontinuance of supplemental oxygen use owing to reduction in dyspnea and improved physical performance may not be warranted in lieu of continued exertional desaturation.

Clozapine-Induced Peripheral and Pleural Fluid Eosinophilia

OBJECTIVE To present a case of clozapine-induced peripheral and pleural fluid eosinophilia (PFE). CASE SUMMARY A 28-year-old man who was taking clozapine for bipolar disorder presented with a 2-week history of increasing shortness of breath. A large right-sided pleural effusion was identified, and eosinophilia was noted in peripheral and pleural fluid. An extensive workup ruled out other etiologies of PFE, and an objective causality assessment revealed that an adverse reaction to clozapine was probable. Clozapine was discontinued and the patient had complete resolution of symptoms, peripheral eosinophilia, and pleural effusion. DISCUSSION Drug-induced pleural disease is uncommon. Nearly 30 drugs have been implicated as causation of pleural disease. Much less common is PFE, with only 8 drugs implicated since 2004. Clozapine is a second-generation antipsychotic approved for treatment of resistant schizophrenia. It is often also used to treat bipolar disorder. Common adverse effects include tachycardia, somnolence, weight gain, and sialorrhea. Uncommon adverse reactions include pancreatitis and agranulocytosis. Through 2009, 11 cases of clozapine-induced pleural effusion, with and without polyserositis, have been reported; however, pleural fluid studies to demonstrate eosinophilia have not been done. CONCLUSIONS To our knowledge, this is the first documented report of clozapine-induced peripheral eosinophilia and PFE. Clinicians should consider clozapine as a possible cause of these reactions.

SPIRAL COMPUTED TOMOGRAPHY IN THE EVALUATION OF PULMONARY EMBOLISM

Determining the presence or absence of thromboembolic disease can often be problematic. Traditional diagnostic algorithms are reviewed and discussed. Spiral CT technology allows a relatively noninvasive visualization of the pulmonary vasculature and is a promising new diagnostic modality for acute and chronic thromboembolic disease. Its potential roles are discussed, and a new diagnostic algorithm is proposed.

Tracheobronchial amyloidosis managed with multimodality therapies.

Amyloidosis is a systemic disease involving abnormal extracellular deposition of amyloid and autologous fibrillar protein material in β-pleated sheets. Accumulation of this abnormal protein leads to organ dysfunction, although respiratory tract involvement is rare. We present two cases of tracheobronchial amyloidosis successfully treated with surgery and radiation.

Postcontrast CT in the diagnosis and assessment of response to thrombolysis in massive pulmonary embolism.

We present a case of massive acute pulmonary embolism where contrast enhanced helical CT was compared with standard angiography for diagnosis and for monitoring subsequent response to thrombolytic therapy. There was very close concordance of the findings on these modalities suggesting that contrast enhanced helical CT may be an easy and reliable alternative to standard angiography.

Selective decontamination of the digestive tract in ICU patients

Source Citation Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotic...

ACP Journal Club. Review: ACE inhibitors reduce risk for pneumonia.

Source Citation Caldeira D, Alarcao J, Vaz-Carneiro A, Costa J. Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic revie...