British journal of diseases of the chest最新文献

Rehabilitation of patients with chronic respiratory disease has tended to be neglected in the past, partly because of a generally pessimistic view of their prospects. Simple programmes of exercise training can produce measurable increases in exercise tolerance and sometimes great improvements in quality of life for respiratory patients. The effects of exercise seem to be through improvement in exercise efficiency. A full rehabilitation programme also involves an attempt to deal with patients' psychological problems and to help them regain independence in all aspects of their lives. The opportunity exists to improve the lot of a large group of people, at a relatively modest cost.

We conducted a double-blind, randomized crossover trial to evaluate whether oral terbutaline (2.5 mg orally three times daily for a week) increased the force of diaphragmatic contraction in normocapnic patients with chronic obstructive pulmonary disease. Ten patients with moderate to severe airway obstruction completed the trial. Compared with placebo, terbutaline produced a mean increase of 5.8 cmH₂O in peak inspiratory mouth pressure and a mean increase of 5.0 cmH₂O in transdiaphragmatic pressure during a maximal inspiratory manoeuvre. These small changes with terbutaline failed to achieve statistical significance. Also, terbutaline failed to alter flow rates (FEV₁, $\text{V}\text{̇}{}_{\mathrm{max50}}$) or patients' dyspnoea ratings using two separate clinical scales (Pneumoconiosis Research Unit Score and the Modified Dyspnoea Index). Because all observed changes in respiratory muscle strength were small and because the trial had power to detect small changes in inspiratory mouth pressures, we suggest that oral terbutaline at the dose administered in this study has little noteworthy effect on respiratory muscle strength in normocapnic patients with chronic obstructive pulmonary disease.

Bronchoalveolar lavage (BAL) cell counts are used to assess ‘alveolitis’ in patients with interstitial lung diseases (ILD) but inflammatory cells from airways can contribute to the differential cell count. To determine what BAL volume samples airway cells in patients with ILD we measured the proportion of bronchial epithelial cells (BECs) in four successive 25 ml aliquots in a single lung subsegment in 23 patients with ILD (cryptogenic fibrosing alveolitis (CFA) four, rheumatoid lung (RL) three, asbestosis (ASB) 11, sarcoidosis (SARC) five). Cells recovered from the first two 25 ml lavages exhibited higher proportions of BECs (15±14% and 9±2% respectively) than those from the rermaining two aliquots (3±1%, 3±1%, each P<0.01), suggesting that the first 50 ml BAL preferentially sampled airway cells compared to the second 50 ml BAL. To evaluate airway and alveolar inflammatory cell proportions in ILD we performed two separate 50 ml BALs (samples I and II) in a single subsegment in 38 patients with ILD (CFA seven, RL five, ASB 19, SARC seven) and measured the proportions of recovered cells in each sample separately and combined. Seven control individuals were also studied. Sample I contained 1–67% (mean 26±3%) of the total recovered cells. Neutrophil (PMN) proportions were higher in sample I compared to sample II in CFA (20±6 vs 8±2%), RL (30±9 vs 8±2%) and ASB (12±2 vs 7±1%), P<0.05 for each, but were similar in samples I and II in patients with SARC (3±1 vs 2±1%) and controls (2±1 vs 2±1%). In combined samples (I+II), absolute PMN proportions were up to 8% higher than in sample II alone whereas absolute lymphocyte proportions were up to 8% less than in sample II alone. These data suggest that separate processing of the fluid recovered from the first 50 ml BAL in ILD patients provides information on the location of inflammatory cells and improves the accuracy of BAL cell counts.

Giant cell arteritis (GCA) may present as pyrexia of unknown origin with profuse night sweats, pain on mastication, headache, pain in the region of the temporal arteries, polymyalgia rheumatica, myocardial infarction or dissecting aortic aneurysm (1). Few cases with pulmonary involvement have been described. We report a patient with temporal arteritis preceded by pulmonary vascular disease.

We describe four patients with bilateral pleural effusions progressing to diffuse progressing to diffuse pleural thickening for which we have been unable to find any evidence of an infective, embolic or occupational aetiology. In order to avoid confusion with diffuse pleural thickening attributable to asbestos-related disease, the term cryptogenic bilateral fibrosing pleuritis is suggested.

The patients differed from those with pleural shadowing due to asbestos in that none of them gave a history of asbestos exposure, all were ill, presented with chest pain which was not always pleuritic in character, and had dyspnoea, cough or malaise. They had pleural effusions of variable size, pleural shadowing radiographically and raised sedimentation rates. Computed tomography revealed bilateral extensive pleural thickening in all cases. All four were HLA B44 positive.

Histology showed that in all cases the pleura was thickned by fibrous tissue. Both layers were affected and the pleural space was often obliterated. Otherwise the plaural surface was covered by organizing fibrin. Focal collections of lymphocytes were often present when the fibrous tissue abutted on the subpleural fat. No asbestos bodies were seen in any of the cases and in one patient electron microscopic fibre counts showed no excess of asbestos.

Pleural decortication was successful in three patients. In one of these, contralateral disease was successfully controlled with corticosteroids, but the fourth patient has not improved on corticosteroids.

Pulmonary involvement in ulcerative colitis usually presents as a rapidly progressive cough with copious amounts of sputum. Although it is rare, distressing symptoms may be relieved by inhaled steroids i 50–60% of cases. Three case reports are presented along with a review of the features of 28 other cases