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Study Objective Our objective was to determine the extent to which patterns of diagnostic and therapeutic practice differ among hospitals caring for acutely ill hospitalized asthmatic patients in a single city. Design Our study comprised a retrospective review of the records of patients admitted to the hospital for the treatment of acute asthma. Setting Three large teaching hospitals in Boston were the setting. Patients One hundred twenty-seven patients between 18 and 50 years of age who were admitted to the medical services specifically for the treatment of asthma were studied. Interventions There were no interventions. Measurements and Main Results For this group of patients with similar histories of asthma, clinical presentation, and severity of asthma, the diagnostic tests used within 12 hours of admission and the frequency and volume of diagnostic laboratory testing throughout the admission differed significantly among the three hospitals. Spirometry, the test bearing most directly on the severity of the asthmatic attack, was not used routinely as a criterion for admission or discharge at any of the hospitals. Other tests of uncertain efficacy, such as chest x-ray films, were used frequently at some of the hospitals. Patients at all three hospitals were treated similarly with intensive combined regimens of methylxanthines, sympathomimetics, and corticosteroids and had similar mean lengths of stay. The use of chest physical therapy, which has not yet been demonstrated to be effective in acute asthma, differed significantly among the three hospitals. Conclusions We conclude that considerable variability exists in the diagnostic evaluation acutely ill hospitalized asthmatic patients in the three hospitals; little variability exists in the pharmacologic treatment of these patients. In the absence of data on outcome regarding functional improvement and reductions in morbidity, we are unable to recommend a preferred pattern of practice from this study.

We report here our experience in achieving remission in a 20-year-old man with pulmonary capillary hemangiomatosis (PCH) with atypical endotheliomatosis following therapy with doxycycline. PCH is a rare disorder characterized by proliferating capillaries that invade the pulmonary interstitium and alveolar septae, and occlude the pulmonary vasculature. The patient's symptoms, lung function, and radiographic findings had worsened despite treatment with both prednisone and alpha-interferon. He was considered to be a candidate for transplantation. Given the elevated levels of basic fibroblast growth factor (bFGF) in urine and the capillary proliferation noted on biopsy specimens, we elected to treat the patient with doxycycline, a matrix metalloproteinase and angiogenesis inhibitor. Following several weeks of therapy, a gradual resolution of symptoms was noted, with normalization of pulmonary function test results and urine bFGF levels. After 18 months of therapy, the patient remains in complete remission.

Study objectives: We tested the hypothesis that breathing 100% oxygen could result in selective pulmonary vasodilatation in patients with pulmonary hypertension, including those patients who would not meet current Health Care Finance Administration guidelines for long-term oxygen therapy. Design, setting, and patients: From 1996 to 1999, 23 adult patients (mean SEM age, 51 4 years) with pulmonary arterial hypertension without left-heart failure underwent cardiac catheterization in a university teaching hospital while breathing air and then 100% oxygen. Measurements and results: Treatment with 100% oxygen increased arterial oxygen saturation (91 1% to 99 0.1%, p < 0.05) and PaO2 (64 3t o 309 28 mm Hg, p < 0.05). Treatment with 100% oxygen also decreased mean pulmonary artery pressure (56 3t o 53 2m m Hg, p < 0.05) and increased cardiac index (2.1 0.1 to 2.5 0.2 L/min/m 2 ,p < 0.05). Calculated mean pulmonary vascular resistance (PVR) decreased from 14.1 1.4 to 10.6 1.0 Wood units (p < 0.05). Vasodilatation with 100% oxygen occurred preferentially in the pulmonary circulation (PVR/systemic vascular resistance, 0.53 0.04 to 0.48 0.03; p < 0.05). The magnitude of the PVR response to oxygen therapy was correlated only with decreasing patient age (r 0.45, p < 0.05). Conclusions: Treatment with 100% oxygen is a selective pulmonary vasodilator in patients with pulmonary hypertension, regardless of primary diagnosis, baseline oxygenation, or right ventricular function. Development of disease-specific oxygen prescription guidelines warrants consideration. (CHEST 2001; 120:1547–1555)

Bilateral volume reduction surgery (VRS) improves lung function for selected patients with emphysema. However, predictors of outcome are not well defined. We reviewed the preoperative characteristics of the first 47 consecutive patients who underwent bilateral VRS at the Massachusetts General Hospital in order to define potential predictors of unacceptable outcome. Preoperative data included spirometry, plethysmography, diffusion of carbon monoxide (Dco), maximum inspiratory pressure (MIP), maximum expiratory pressure, resting arterial blood gases (ABG), cardiopulmonary exercise testing with ABG and lactate sampling, and radionuclide ventriculography. Prepulmonary and postpulmonary rehabilitation 6-min walk tets (6MWT), and preoperative chest CT scans were also obtained. Twenty-two subjects were male and 17 of the subjects were on the lung transplant list. Patient characteristics included age of 60.5 +/- 7.5 years, FEV1 of 0.67 +/- 0.20 L, total lung capacity of 7.56 +/- 1.7 L, Dco of 7.40 +/- 4.1 mL/min/mm Hg, and PaCO2 of 41.6 +/- 6.4 mm Hg (mean +/- SD). The FEV1, vital capacity, MIP, resting room air PaCO2, prepulmonary and postpulmonary rehabilitation 6MWT, and PaCO2 at maximum oxygen consumption correlated with length of hospitalization (p0.05). Based on analysis of 41 of 47 patients for whom there were complete data, the inability to walk more than 200 m on the 6MWT before or after preoperative pulmonary rehabilitation, and resting PaCO2or = 45 mm Hg were the best predictors of an unacceptable outcome. If either of these characteristics was present, six of 16 vs zero of 25 died (Fisher's Exact Test, p = 0.0025, one-tailed) and 11 of 16 vs four of 25 had hospital courses21 days (p0.002). Both the 6MWT200 m and resting PaCO2or = 45 mm Hg alone correlated with death (p = 0.004 and p = 0.012, respectively) and the resting PaCO2or = 45 mm Hg correlated with hospital days21 (p = 0.0002). In conclusion, the data suggest that the inability to walk at least 200 m in 6 min before or after pulmonary rehabilitation and a resting room air PaCO2or = 45 mm Hg are excellent preoperative predictors of unacceptable postoperative outcomes.

The usual method of weaning mechanically ventilated patients from high FIo2 in our ICU, in which housestaff ordered all ventilator changes in an unstandardized manner (control group), was compared to a nurse-directed protocol that used a single arterial blood gas (ABG) analysis and multiple pulse oximetry measurements. The protocol required an ABG to be obtained upon the initiation of intubation/mechanical ventilation, followed by pulse oximetry measurements obtained in accordance with a standardized timetable. Decreases in FIo2 were guided by these results. It was concluded that a nurse-directed oxygen weaning protocol utilizing a combination of a single ABG and multiple pulse oximetry measurements was safe, reduced the need for ABGs, and decreased the duration of patient exposure to toxic oxygen concentrations.

We characterized T-lymphocyte subsets in peripheral blood of smokers (N=60) and nonsmokers (N=35). Total T-lymphocytes and T cell subsets were similar to nonsmokers in light and moderate smokers. In heavy smokers, total OKT3 + cells were increased, the percentage of OKT4 + cells was decreased, and percentage and total number of OKT8 + cells were increased. The ratio of OKT4 + to OKT8 + lymphocytes was decreased in heavy smokers. The percentage of OKT8 + cells and the OKT4 + /OKT8 + ratio returned to normal in heavy smokers six weeks after they stopped smoking. These findings suggest that cigarette smoking causes reversible alterations in immunoregulatory T cells.

To determine if fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage impairs pulmonary function in normal subjects or those with sarcoidosis, we measured flow-volume loops, thoracic gas volume, and single breath carbon monoxide diffusing capacity before, one half hour and 24 hours after lavage. We studied 12 normal subjects; six underwent a large volume lavage (approximately 500 ml saline instilled), and six underwent a small volume lavage (approximately 175 ml). Five subjects with sarcoidosis also had a small volume lavage. Six control subjects underwent FOB without lavage. The FOB alone produced no significant changes in pulmonary function one half hour after the procedure. Small volume lavage in normal subjects produced no change except for a 16.3 +/- 5.1 percent (mean- +/- SEM) decline in peak expiratory flow rate (p less than .05) one half hour postlavage which returned to normal by 24 hours. This contrasts with sarcoidosis subjects in whom forced expiratory volume in one second, peak expiratory flow rate, and vital capacity declined by 20 +/- 4.8 percent, 26.7 +/- 7.3 percent, and 15.2 +/- 4.1 percent, respectively, (all p less than 0.05) one half hour postlavage. No change occurred in total lung capacity or diffusing capacity. Only with large volume lavage did decrements in lung function occur in normal patients that were comparable to those seen in the sarcoidosis subjects. Our findings suggest that bronchoalveolar lavage in normal patients can be associated with a significant and volume-related decline in pulmonary function and that in subjects with sarcoidosis, the deterioration is more pronounced.