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In a retrospective review of patients subjected to right heart catheterization, case records from 109 consecutive patients with chronic obstructive pulmonary disease (COPD) and wedge pressureor =15 mm Hg on exercise were analyzed. Patients were separated into group 1, resting wedge pressure (P macro w)15 mm Hg and difference between P macro w and right atrial pressure (P macro ra) change on exercise5 mm Hg (n = 54), group 2, same P macro w at rest but increase in macro on exerciseor =5 mm Hg, being higher than that of P macro ra (n = 34), and group 3, P macro wor =15 mm Hg at rest (n = 21). The occurrence of left heart disease increased from group 1 to group 3 (19, 53 and 71%, respectively), and the slope of the P macro w/stroke index relationship was lowest in group 3. High P macro w on exercise can be explained by the pressure rise in the cardiac fossa associated with lower lobe gas trapping in group 1, which showed the most severe airflow limitation, decreased left ventricular compliance in group 2, and heart failure in group 3.

Study objective To analyze predictors of survival for patients receiving home long-term oxygen therapy (LTOT) or prolonged mechanical ventilation (PMV) according to the cause of chronic respiratory insufficiency (CRI) and the patient's physiologic data. Design Analysis of a nationwide database (ANTADIR Observatory). Setting The national nonprofit network for home treatment of patients with CRI Association Nationale pour le Traitement a Domicile de l'Insuffisance Respiratoire Chronique (ANTADIR): founded in France in the 1980s. Patients There were 26,140 patients receiving LTOT or PMV (noninvasive or via tracheostomy) between January 1, 1984 and January 1, 1993 (chronic bronchitis, 12,043; asthma, 1,755; bronchiectasis, 1,556; emphysema, 551; tuberculosis sequelae, 4,147; kyphoscoliosis, 1,574; neuromuscular diseases, 1,097; pneumoconiosis, 919; and fibrosis, 2,498). Measurements and results Survival analysis was performed using the actuarial and the Cox's semiparametric model. The mean survival for patients with chronic bronchitis is 3 years. Survival is slightly better for patients with bronchiectasis and asthma and worse for those with emphysema. Patients with kyphoscoliosis and a neuromuscular disease have the longest survival (8 and 6.5 years, respectively). Patients with CRI due to tuberculosis sequelae experience the same survival as COPD patients (3 years). Prognosis is the worst in patients with pneumoconiosis or fibrosis: 50% of these patients die during the year following the beginning of home treatment. The association of an obstructive lung disease worsens the prognosis of patients with kyphoscoliosis or neuromuscular disease and tends to bring the survival rate of the patients with pneumoconiosis or fibrosis closer to that of COPD patients. In COPD, male sex, older age, lower body mass index (RMI), FEV 1 percent predicted, PaO 2 , and PaCO 2 are independent negative prognostic factors. For tuberculous sequelae and kyphoscoliosis, female sex, younger age, a high RMI, PaO 2 , and PaCO 2 (and for kyphoscoliosis a higher FEV 1 /vital capacity [VC] ratio) are all independent favorable prognostic factors. In pulmonary fibrosis, a lower PaO 2 and PaCO 2 values, a lower VC percent predicted, and a higher FEV 1 /VC ratio are negative prognostic factors. Conclusions The ANTADIR Observatory allows a unique opportunity to analyze long-term survival of a large population with CRI treated at home.

Disturbances in hormonal systems involved in sodium and water homeostasis are common during respiratory insufficiency. To investigate the role of hypercapnia, we designed a study to examine the hormonal response to acute hypercapnia induced at constant cardiac filling pressures and without hypoxemia. Seven sedated patients with COPD receiving mechanical ventilation were studied during five successive periods. Hemodynamics, arterial blood gases, and plasma hormone levels (atrial natriuretic peptide, renin, angiotensin II, aldosterone, vasopressin) were measured three times during 60 min of acute hypercapnia (52 +/- 5 mm Hg) and at control periods, before (36 +/- 4 mm Hg) and after (42 +/- 3 mm Hg) acute hypercapnia. During acute hypercapnia, mean pulmonary arterial pressure and cardiac output were increased without variation of other measured cardiorespiratory data and hormonal levels when compared with control values. After acute hypercapnia, cardiorespiratory variables returned to control values without variations of hormonal levels. Our results show that moderate acute hypercapnia does not significantly influence the hormonal levels when cardiac filling pressures and sympathetic tone remain stable. We suggest that changes in those plasma hormones involved in salt and water homeostasis during acute hypercapnia are secondary to hemodynamic changes induced by acute respiratory failure and not to acute hypercapnia per se.

OBJECTIVE The purpose of this study was to compare the effects on exertional dyspnea and exercise capacity of square wave (bilevel) cycle ergometry endurance exercise training (SWEET) and comprehensive directed breathing vs. walking while pushing an OxCar and traditional diaphragmatic breathing for male smokers with normal spirometry but reduced exercise capacity. DESIGN This was a prospective randomized trial of 24 unmedicated men with exertional dyspnea assigned to SWEET or OxCar groups. Exertional dyspnea was assessed using the Borg scale during four tests: incremental exercise, constant exercise at 80% of the peak work rate (PWR) (maximum tolerated for 3 mins before exhaustion), SWEET, and 6-min walk test. Both groups trained for 45 mins, 5 days a week, for 6 wks. Before, during, and after training, 32 lung function parameters were studied at ventilatory anaerobic threshold, at PWR, and during incremental exercise (30 W/3 mins). RESULTS For the SWEET group, exertional dyspnea and the dyspnea index decreased during incremental exercise, at the ventilatory anaerobic threshold, and at PWR (P < 0.01). At the ventilatory anaerobic threshold, oxygen consumption increased by 74%; minute ventilation, 30%; tidal volume, 91%; and ventilatory efficiency and oxygen pulse (O(2)P), 25%; and breathing rate (breathing frequency) decreased by 32% (all significant at P < 0.001). At PWR, oxygen consumption increased by 30%; minute ventilation, 37%; breathing rate, 21%; and ventilatory efficiency and oxygen pulse, 25% (P < 0.01). During the full incremental test, minute ventilation, breathing frequency, and heart rate (cardiac frequency) decreased significantly (P < 0.01). In addition, there was significant improvement (P < 0.001) in SWEET intensity by 63%, constant exercise intensity at 80% of PWR by 38%, and 6-min walk test by 30%. No significant changes were observed for the OxCar group other than for the 6-min walk test, which increased by 7% (P < 0.05). CONCLUSIONS This study suggests that the decline in exercise tolerance for male smokers can be reduced by intensive exercise training (SWEET) and comprehensive directed breathing but not by moderate training and traditional diaphragmatic breathing. Thus, some smokers can be helped despite continuing to smoke.

Cytokines are widely involved in physiologic as well as immunoinflammatory and fibrosing processes of the lung. The aim of this work was to study, by bronchoalveolar lavage, two groups of human interstitial lung diseases (ILD) with fibrosing propensity (ie, idiopathic pulmonary fibrosis [IPF], n=10; and coal worker's pneumoconiosis [CWP], n=15). Patients were compared with nonsmoker control subjects (n=20). Cellularity, proteins, and phospholipids were determined in the alveolar fluids. In addition, two cytokines (interleukin-6 [IL-6] and interferon-gamma [IFN-γ]), which are presumed to possess respective antifibrotic and profibrotic activities, were measured in the respiratory tract. Compared with control subjects, IPF and simple CWP showed alveolar hypercellularity (p

To define more clearly the value of home mechanical ventilation by tracheostomy (HMVT) in patients with advanced COPD, a retrospective French multicenter study group analyzed the prognostic factors and long-term survival of 259 patients with severe COPD, who were tracheostomized for at least 1 year. Seventy-eight percent of the patients died by the end of the observation period. The actuarial survival rate for the overall study population was, therefore, 70 percent at 2 years, 44 percent at 5 years, and 20 percent at 10 years. These results appear to be better than those of the major published series and compare to the prognosis of COPD patients treated by long-term oxygen therapy (LTO) 15 hr/24 hr. The parameters most closely correlated with a survival for more than 5 years were age 2 >55 mm Hg in room air during the 3 months after tracheostomy (p

In assessing the effectiveness of lower-limb and upper-limb nonspecific physical training, we have considered 3 objectives in this study: (1) determination of clinical and functional actual state in patients with chronic airway obstruction (CAO), before and after training; (2) determination of the tests, level of work, and duration of the session training as well as how to increase the training load throughout the training program; and (3) the "particular" upper-limb exercise training in patients with CAO. Many personal factors such as psychologic (personality, degree of patient motivation), alcohol and smoking habits, physical activity, malnutrition, as well as routine tests, at rest and maximal exercise, including the control of metabolic acidosis (lactate) and arterial blood gases (or at least of SaO2), should be considered. Exercise training has the potential to improve exercise tolerance in those who develop metabolic acidosis. The pattern of lactates during exercise represents a good criterion on the selection of patient's training. Two ergospirometric strategies, at high intensity exercise, established from the anaerobic threshold (AT) are described: (a) the above AT 45 min constant exercise (high work rate), at 60% of the difference between AT and maximum VO2 or 80% of the maximal tolerated power (MTP), and (b) the "45 min square-wave endurance exercise test" (SWEET), simulating an interval training session, established from the MTP and the AT. To the SWEET's base (% MTP from AT or aerobic training), a peak of 60 s at MTP (anaerobic training) is added every 5 min. While those 2 protocols, after 6 to 8 weeks of training, lactate and ventilation were lower for identical work rate. In addition, endurance (time in "a" and total physical work in "b") increased up to 60%. Further, maximal exercise ventilation and maximum VO2 increased after SWEET training. Roughly every 7 training sessions, a 10% to 15% reduction in heart rate (HR), during the training program, allows the patient to increase the work rate of the sessions. Evaluation of training the upper limb in patients with CAO requires measurements of MTP and maximum VO2. With the upper limb (wheelchair ergometer), Wmax, maximum VO2, and HR represent 30%, 65%, and 95%, respectively, of the lower limb (ergometer). Further, some expiratory and inspiratory accessory muscles show electromyographic fatigue at the MTP upper-limb level. This may contribute to the rationale for training respiratory muscles.(ABSTRACT TRUNCATED AT 400 WORDS)

Study objective — The aim was determine the early effect of a posture change from supine (S) to legs raised 30° above the table plane (LR) on haemodynamics in patients with chronic lung disease. Study design — Right heart catherisation was performed as part of a routine evaluation. Pulmonary arterial, pulmonary wedge, right atrial, and systemic arterial pressure were monitored at rest supine and during 8 min (steady values) after LR. Pulmonary blood volume was measured by double dye dilution, at rest S and after 1 and 8 minutes LR, in 14 patients; cardiac output was measured by thermodilution in the remaining 15 subjects, during S and 1, 4, and 8 minutes LR. Subjects — 29 patients with chronic pulmonary disease of various types, mainly chronic bronchitis and emphysema, were studied when in a stable clinical condition, with no signs of heart failure. Measurements and main results — Raising the legs produced a sharp increase in all the pressures measured, with a subsequent decline towards a steady value slightly higher than during S. Pulmonary blood volume increased in all patients initially, but stayed elevated only in the normocapnic patients; in the patients with hypercapnia it decreased from 1 to 8 min LR. The pulmonary blood volume change showed a significant correlation with Paco2(p

In an attempt to elucidate the origin of the so-called idiopathic spontaneous pneumothorax (ISP), clinical examination, pulmonary function tests, and computed tomography (CT) with visual quantification and density analysis were performed in 20 young patients two months after an ISP episode. Twenty controls were recruited for CT. The chest roentgenograms were normal in the two groups. The results indicated the presence of various types of emphysematous lesions (EL) in the ISP group located predominantly in the apical fields with subpleural location in 16 patients. Interestingly, diffuse but moderate centrilobular emphysema was noted in 12 of 20 patients. The EL visual quantification was always less than 5 percent of the CT slices' total areas. The lung mean density shifted significantly toward the air density in the patient group (patients: -743 +/- 57.5 HU vs controls -713 +/- 59.5 HU, p less than 0.01). These findings suggest that CT may be useful for early assessment of EL in patients with ISP.

Gimenez M, Servera E, Vergara P, Bach JR, Polu J-M. Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity. Arch Phys Med Rehabil 2000;81:102-9. Purpose: To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease (COPD) and to compare its outcomes with those of commonly prescribed moderate exercise. Design: Prospective, randomized trial. Setting: A work physiology laboratory. Patients and Methods: The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer. The patients then exercised 45 minutes daily, 5 days a week for 6 weeks, working 2.03 ± 0.4kJ/kg per session. They were matched with 6 COPD patients who pushed an O 2 cart for 45 minutes daily, 5 days a week for 6 weeks, working 1.44 ± .35kJ/kg per session. Results: A 45 minute maximal regimen was established by alternating 1-minute peak exercise at peak VO 2 levels with 4 minutes at the ventilatory anaerobic threshold or at 40% of peak VO 2 . Maximal bilevel training significantly decreased dyspnea at rest ( p ≤ .01) and the blood lactate level during submaximal exercise ( p 2 and total physical work ( p p p p 2 cart pushers significantly improved only on the 12-minute walk ( p Conclusions: A maximally intense anaerobic exercise program can be created for most COPD patients that can significantly improve both skeletal and respiratory muscle strength and endurance as well as dyspnea and physiologic parameters. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

During the clinical course of chronic lung disease, acute exacerbations due to pulmonary infection are often observed. These may lead to cardiorespiratory failure, with clinical and haemodynamic signs of right heart failure.1 When the patients recover from the acute episode, blood gases and pulmonary haemodynamics usually return close to their values in stable clinical condition: the evolution of pulmonary artery pressure is less than 1 mmHg per year when patients are studied in stable condition.2,3

Six pulse oximeters with finger probes were studied in three groups of 17 hypoxemic patients with COPD aged 50 to 75 years. Transcutaneous arterial oxygen saturation (SpO 2 ) was measured with the Nellcor N101 (oximeter 1a), the Ohmeda Biox III (oximeter 1b), the Nellcor N200 (oximeter 2a), the Critikon Oxyshuttle (oximeter 2b), the Radiometer Oxi100 (oximeter 3a), and the Ohmeda Biox 3700 (oximeter 3b). The SpO 2 was compared with SaO 2 measured in simultaneously withdrawn samples of arterial blood (Radiometer OSM2) at three 20-minute steady-state levels of Flo 2 ranging from 0.21 to 0.40 (SaO 2 , 62 to 100 percent). The bias (mean SpO 2 -SaO 2 difference) and the error in precision (SD of the differences) were both below 4 percent for instruments 1a and 1b and remained below 1.2 and 3 percent, respectively, for the others. A good agreement between SpO 2 and SaO 2 , as reflected by the Bartko intraclass correlation coefficient, was observed in instruments 2a, 3a, and 3b. The individual relationships between SpO 2 -SaO 2 differences and SaO 2 appeared to be linear and parallel. With four instruments (1a, 1b, 2a, and 2b), the mean slope of this relationship was negative, showing a systematic instrumental error: the lower the SaO 2 , the larger the overestimation of SaO 2 . The scattering of the data (precision) principally reflects a subject source of error. In most instruments a technical adjustment could greatly improve instrumental errors and accuracy. The correction of the errors due to between-subject variation would require a system of calibration adjustable by the users to each individual.

Because of the highly viscoelastic properties of bronchial mucus and its heterogeneity, the sputum requires an homogenization step. As our long-term project was to study the sputum concentrations of different proteases and their inhibitors. we tried to perfect a new homogenization method, since the different methods previously described-chemical [l-3], mechanical [4,5], enzymic [6,7] or more general biochemical [8]-did not seem capable of achieving this objective. The aim of this project was to perfect an homogenization method, based solely on ultrasound, and to define experimental conditions such that the enzymic activities (trypsin-like, chymotrypsin-like, elastase, collagenase) and the integrity of the cells (leukocytes and bacteria) would be preserved.

A consecutive series of 40 patients (39 men, one woman; mean age 54.1 +/- 8.2 years) with chronic obstructive lung disease (COLD) underwent right heart catheterization and 2-D echocardiographic examination within 72 hr. An adequate 2-D echocardiographic study was obtained in 32 patients (80 percent) using the apical and/or subcostal views. Mean pulmonary artery pressure at rest and during exercise were correlated with right ventricular diameters and areas in end-systole and end-diastole (r = 0.63 to 0.73). Correlations between right ventricular free wall thickness and pulmonary artery pressure were weak (r = 0.51 and 0.57). Right ventricular end-diastolic pressure was also weakly correlated with right ventricular dimensions (r = 0.45 to 0.51), whereas right ventricular area fractional shortening was not correlated with hemodynamic parameters. Patients with previous episode of right heart failure had larger right ventricles than those without such episodes. Thus, 2-D echocardiography appears useful to study the right heart chambers in patients with COLD.

A double-blind study with placebo control was carried out in 20 patients with chronic bronchitis to analyze the effect of oral terbutaline on mucociliary transport and sputum properties. Terbutaline (2.5 mg tablets) was given 3 times a day for 1 week. The clinical score, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) significantly improved after treatment with terbutaline and confirmed the bronchodilating action of this drug. The mucociliary clearance measured with a radioactive aerosol tracer did not significantly differ after treatment with terbutaline and placebo although the initial site of aerosol deposition was similar in the two groups before and after treatment. The viscoelastic properties of sputum and their in vitro transport rate on the frog palate were not modified by terbutaline. The decrease in sputum volume and serum albumin concentration suggests a bronchial anti-inflammatory effect of this medication.

This study aimed to assess the effect of hypoxemia on theophylline disposition. Ten patients with a mean (+/- SEM) of 58 +/- 3 years with COLD (PaO2 55 +/- 1 mm Hg, PaCO2 46 +/- 2 mm Hg, and pH of 7.39 +/- 0.01) were hospitalized to have oxygen therapy. Before starting O2, they received intravenously, 4 mg/kg of theophylline over a 20-minute period; blood samples and urine were collected for six hours. The results suggested that hypoxia does not influence the disposition of theophylline or its metabolites.

L'hypertension artérielle pulmonaire (HTAP) est une maladie rare, caractérisée par une fibrose intimale, une hypertrophie de la média et une fibrose adventielle. Les lésions thrombotiques sont fréquentes même en l'absence d'embolie pulmonaire. Après un rappel sur la physiopathologie, le diagnostic et le traitement de l'HTAP, nous avons étudié l'hémostase au cours du cathétérisme cardiaque droit : du sang veineux mêlé a été prélevé chez 43 patients présentant une HTAP, dont 25 patients atteints d'HTAP primitive (HTAPP), 7 patients souffrant d'HTAP post-embolique et 11 patients porteurs d'une HTAP secondaire à une bronchopathie chronique obstructive (BPCO). Nous avons étudié les facteurs endothéliaux, la thrombomoduline ou TM, le "tissue factor pathway inhibitor" ou TFPI, l'activité antigénique du facteur Von Willebrand ou Ag-vWF et le "tissue plasminogen activator" ou tPA et le potentiel de génération et d'inhibition de la thrombine (thrombinographie) chez 21 patients sans traitement anticoagulant. Nous avons corrélé ces résultats aux données hémodynamiques. Il existe une corrélation entre deux facteurs endothéliaux (TFPI et TM) et les données hémodynamiques. La concentration de TM est corrélée avec les paramètres sévérité hémodynamique. Ces résultats soulignent l'importance de la dysrégulation endothéliale dans la physioathologie de l'HTAP et son impact sur la coagulation et probablement la vasoconstriction. Les résultats de la thrombinographie sont en faveur de l'existence d'un état pro-thrombotique. Cette hypercoagulabilité peut être liée à un défaut des systèmes de régulation de la TM et de l'activation de la protéine C. La TM semble jouer un rôle important dans l'HTAP. Le système de la protéine C reste à explorer.

Le principal symptôme de l'hypertension artérielle pulmonaire primitive (HTAPP) est la dyspnée responsable d'une intolérance à l'effort. Les causes de cette limitation sont mieux connues à l'heure actuelle, mais aucune étude ne s'est intéressée spécifiquement à l'évolution hémodynamique à l'effort. Après un rappel sur les connaissances actuelles de la physiopathologie, du diagnostic, du traitement et des données hémodynamiques à l'effort des HTAP pré-capillaires et principalement des HTAPP, nous avons étudié les résultats hémodynamiques au repos et à l'effort de 3 groupes de patients : 21 sont porteurs d'une HTAPP, 5 d'une HTAP post-embolique et 10 d'une HTAP secondaire à une bronchopathie chronique obstructive (BPCO). Nous avons montré que les patients porteurs d'une HTAPP ou d'une HTAP post-embolique ont une HTAP plus sévère avec des pressions artérielles pulmonaires moyennes (Papm) et des résistances vasculaires pulmonaires plus élevées. Cette HTAP plus grave est responsable d'un retentissement cardiaque plus important dès le repos comme en témoigne l'effondrement du débit cardiaque et du volume systolique et l'augmentation des pressions de remplissage du coeur droit. A l'effort, la Papm augmente, aggravant encore le retentissement ventriculaire droit. Pour répondre à la demande d'oxygène en périphérie au cours de l'exercice, ces patients majorent leur débit cardiaque mais dans de faibles proportions. Cette majoration est entièrement sous la dépendance de l'augmentation de la fréquence cardiaque. Notre étude n'a pas retrouvé de différence hémodynamique entre les patients ayant une HTAPP et ceux porteurs d'une HTAP post-embolique. Le test de marche de 6 minutes, déjà corrélé à la survie des patients HTAPP, s'est avéré être un bon témoin de la gravité de l'HTAP, les patients ayant parcouru la plus faible distance étant ceux qui présentent les valeurs hémodynamiques les plus sévères.