Compromised Pulmonary Function Research Articles

EVA is an acceptable alternative to ABVD in patients with advanced Hodgkin’s and compromised pulmonary function: 8-year follow up

6683 ABVD is the standard treatment of advanced Hodgkin’s disease(HD). However two of the components,Bleomycin and DTIC have significant toxcicities such as lung fibrosis and emesis,and also uncertain single agent activity. The EVA regimen (VP16,Vinblastine and Doxurubicin) is an attempt to substitute a known active agent ie:VP16 for Bleo and DTIC. A series of 26 pts with advanced HD and a history of prior lung disease or radiation treatment were selected for this study. They included 7 stage2/bulky mediastinal tumors and all received consolidation XRT. The remaining pts recieved EVA only. The median F/U was 108n months. EVA: Etoposide 100mg/m2 days 1–3,VBL 6mg/m2 day-1 and Doxurubicin 50mg/m2 day-1. All drugs given iv. Cycles repeated Q.3 wk x 6 cycles. Results: Complete response(CR) was achieved in 25/26(96%). Of these 25 responders 8 pts relapsed in a median of 10 months(range 3–22). In F/U 17/26 pts had no evidence of recurrent HD, resulting in progression-free survival for the entire group of 65% at 108 mo. Five of the 8 relapsers achieved a 2nd-CR and were alive and disease-free at F/U at 108 mo. In the entire series 4 pts(15%) died of HD (one patient was induction failure and 3 pts relapsed post 1st CR). 22/26(85%) of pts continued free of disease. There was no pulmonary toxicity. Toxicities in general was comparable to ABVD. Conclusion: The EVA regimen has an overall survival comparable to standard ABVD in our study with the added advantage of lacking lung toxicity in this susceptible group of pts. No significant financial relationships to disclose.

Threshold effect of urinary glycosaminoglycans and the walk test as indicators of disease progression in a survey of subjects with Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)

A cross-sectional survey in individuals affected with the lysosomal storage disease Mucopolysaccharidosis VI (MPS VI) was conducted to establish demographics, urinary glycosaminoglycan (GAG) levels, and clinical progression of the disease. The survey evaluated 121 bona fide MPS VI-affected individuals over the age of 4 years from 15 countries across the Americas, Europe, and Australasia representing greater than 10% of the estimated world prevalence of the disease. A medical history, complete physical exam, urinary GAG determination, and assessment of several clinical measures related to physical endurance, pulmonary function, joint range of motion, strength, and quality of life were completed for each participant. Although a wide variation in clinical presentation was observed, several general findings were obtained reflecting progression of the disease. Impaired physical endurance, as measured by the distance achieved in a 6-min walk, could be demonstrated across all age groups of MPS VI-affected individuals. High urinary GAG values (>200 mug/mg creatinine) were associated with an accelerated clinical course comprised of age-adjusted short stature and low body weight, impaired endurance, compromised pulmonary function, and reduced joint range of motion. An unexpected result was the predominance of urinary GAG values <100 mug/mg creatinine for those participants over the age of 20 years. Pending the collection of longitudinal data, these results suggest that urinary GAG levels predict clinical morbidity, and longer-term survival is associated with urinary GAG levels below a threshold of 100 mug/mg creatinine.

Predicitve Value of Pretransplant Testing.

Routine evaluation prior to stem cell transplantation generally includes assessment of left ventricular ejection fraction (EF), pulmonary function, renal function, liver function, and functional status. Patients in whom compromised organ function is detected, are often deemed ineligible for myeloablative transplantation. However, the predictive value of specific pretransplant tests is not well documented, and has not been critically analyzed in patients receiving busulfan-based preparative regimens. We analyzed the prognostic value of the pretransplant evaluation performed in 1035 consecutive patients who underwent autologous (n=444) or allogeneic (n=591) transplantation with busulfan-based regimens between 2/84 and 12/03 for acute (250) or chronic leukemia (198), myelodysplasia (50), multiple myeloma (88), or Hodgkin's (139) or non-Hodgkin's lymphoma (303). Ages ranged from 4–75 (median 41). BuCy was given to 477 and BuCyVP16 to 558 individuals.Ninety three patients had EF < 50%, 61 had DLCO < 65%, 103 had elevated creatine, 130 had elevated tranaminases or bilirubin, and 116 had Karnofsky scores < 80%. For the entire group, multivariable analysis demonstrated only Karnofsky score < 80% (P < .001) and elevated LFTs (P=.04) to have significant adverse prognostic influence on survival. Karnofsky score was significant in patients undergoing autologous (P <.001) or allogenic (P <.001) transplantation. Neither EF nor DLCO were predictive of poor outcome for the overall group (P >.2), nor for the autologous or allogeneic transplant groups. However in patients undergoing transplants from unrelated donors (n=119) DLCO < 65% was a significant adverse prognostic factor (P=.004). There was no association of compromised cardiac or pulmonary function with cardiac or pulmonary failure as a primary cause of death. This study suggests that moderately compromised organ function, particularly cardiopulmonary limitations which might not be clinically apparent, are of limited value in prediction of transplant outcome. Direct clinical assessment, including functional status are of much greater value in prediction of outcome. It is hoped that this investigation will stimulate larger studies of pretransplant predictors of outcome with attention to their relevance to specific preparative regimens, sources of stem cells, and other treatment variables.

Outcomes after resection of giant emphysematous bullae

Background Giant emphysematous bullae represent a rare form of emphysematous lung destruction. Surgical resection has traditionally been indicated when there is hyperexpansion of the chest, compromised pulmonary function, and evidence of underlying, relatively normal compressed lung. We review our experience and intermediate-term follow-up after the resection of giant bullae. Methods Forty-three patients underwent resection of giant emphysematous bullae at Barnes-Jewish Hospital between March 1994 and June 2002. All had limiting dyspnea and radiologic evidence of hyperinflated giant bullae compressing adjacent lung parenchyma. Forty-one patients underwent preoperative pulmonary rehabilitation. Twenty-two patients underwent a bilateral procedure and 21 underwent a unilateral procedure. Mean follow-up was 4.5 years. Results One early death occurred on postoperative day 20 from heparin-induced thrombocytopenia and pulmonary embolism. Complications included prolonged air leak of more than 7 days in 23 (53%), atrial fibrillation in 5 (12%), postoperative mechanical ventilation in 4 (9%), and pneumonia in 2 (5%). Kaplan-Meier survival at 1, 3, and 5 years was 98%, 92%, and 89%, respectively. Four late deaths occurred at 1.4, 2.8, 3.5, and 5.9 years. Functional measures preoperatively and at 6 months and 3 years postoperatively were a forced expiratory volume in 1 second L (% predicted) of 1.2 ± 0.6 (34%), 1.9 ± 0.9 (55%), and 1.5 ± 0.8 (49%); residual volume L (% predicted) of 5.1 ± 1.2 (262%), 3.6 ± 1.2 (154%), and 4.1 ± 2.2 (209%); 6-minutes walk (ft) of 1230 ± 361, 1393 ± 300, and 1271 ± 423; supplemental O 2 used continuously (% patients) of 42%, 9%, and 21%; and O 2 used during exercise of 73%, 37%, and 42%, respectively. Conclusions In a contemporary series, giant bullectomy is shown to produce significant immediate functional improvement. This benefit declines with time but persists at least 3 years.

Invited commentary

This paper describes a technique that has worked well for the authors in a small subset of cases that allows partial lung collapse for thoracoscopic procedures. The technique itself appears fairly simple, but in the majority of cases did require the use of carbon dioxide insufflation. This method is designed to replace the need for double lumen endotracheal tubes and single lung ventilation. Our experience has been very good with the use of double lumen endotracheal tubes. They provide optimal visualization of the surgical field for thoracoscopic procedures and, as such, expedite the rapid performance of these procedures. Although the authors suggest no delays in their surgical times by using this technique, I believe it is quite possible, particularly with more advanced surgical procedures, that using this method will increase the operative time, thereby offsetting any cost advantage from avoiding the double lumen endotracheal tubes. In addition, in the last 10 years with over 3,000 procedures using double lumen endotracheal tubes, we have had only one significant airway injury. I believe that this attests to the general safety of the placement of double lumen endotracheal tubes in experienced hands. The need for carbon dioxide insufflation changes the flow of the procedure as we perform it today. In fact, we often do not use trocars at our access sites. Instead, we use a simple skin incision with an incision between the intercostal space and then use standard instruments. Adding the need for CO2 requires keeping seals, and can be cumbersome, while making it difficult to use some of the instrumentation that we normally use. In summary, I believe that for simple procedures this technique can be utilized. However, for the majority, I am doubtful that there is any clinically significant benefit. There may be a small subset where this technique may have a role, such as those that have severely compromised pulmonary function or where the use of a double lumen endotracheal tube is not possible. For the vast majority of cases, I personally will accept the cost of a double lumen endotracheal tube so that I can achieve optimal visualization.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome

A comparison of the end-tidal CO 2 measured by portable capnometer and the arterial P CO 2 in spontaneously breathing patients

An end-tidal CO 2 (ETCO 2) monitor (capnometer) is used most often as a noninvasive substitute for P aCO 2 in anesthesia, anesthetic recovery and intensive care. However, the utility and accuracy of the portable capnometer in spontaneously breathing patients with or without chronic pulmonary diseases has received little recognition. To determine the utility of the portable capnometer in general wards and in in-home care, we examined the correlation between ETCO 2 measured by a portable capnometer and simultaneous P aCO 2 measured in 41 spontaneously breathing patients. TV-ETCO 2 (ETCO 2 measured by tidal volume maneuver) was lower than P aCO 2 by an average of 9.0 mmHg and VC-ETCO 2 (ETCO 2 measured by vital capacity maneuver) was lower than P aCO 2 by an average of 0.5 mmHg. The mean difference between P aCO 2 and VC-ETCO 2 was not statistically significant. Regression analysis showed a close correlation between VC-ETCO 2 and P aCO 2 ( r = 0.91, P < 0.0001). Thus, VC-ETCO 2 was highly correlated with P aCO 2. Furthermore, a close correlation between VC-ETCO 2 and P aCO 2 was also observed in patients with compromised pulmonary function ( r = 0.88, P < 0.0001 in patients with below 70% of FEV 1.0%; r = 0.89, P < 0.0001 in patients with below 80% of %VC). Our studies show that VC-ETCO 2 measured by the portable capnometer gives a reliable point estimate of P aCO 2, and can be useful to evaluate the respiratory condition of spontaneously breathing patients in general wards and in in-home care.

Left diaphragmatic eventration diagnosed as congenital diaphragmatic hernia by prenatal sonography.

Congenital diaphragmatic eventration is an abnormal elevation of the diaphragm resulting from failure of muscle fibers to develop during gestation. A mediastinal shift to the contralateral side may cause significant compression of the affected chest contents, resulting in compromised pulmonary function, especially when both sides are involved. Differentiating between congenital diaphragmatic eventration and congenital diaphragmatic hernia is very difficult but important because eventration has a better perinatal outcome than diaphragmatic hernia has. This report discusses a case of congenital diaphragmatic eventration that was initially diagnosed by prenatal sonography as a diaphragmatic hernia on the left side. In this case, the correct diagnosis was made at the time of surgery shortly after the infant's birth. The defect was repaired by plication, and the infant's outcome was favorable. Although the initial diagnosis was incorrect in this case, the use of sonography can aid in the prenatal detection and diagnosis of congenital diaphragmatic anomalies.

Travellers with pre-existing medical conditions

Medical conditions that influence travel include those that compromise the immunity of the traveller and chronic underlying diseases or infirmities. The former includes HIV, transplantation, malignancy and its treatment, IgA deficiency, asplenia and use of immunocompromising drugs like corticosteroids. Chronic conditions include diabetes mellitus, end stage renal disease, diseases associated with compromised cardiac or pulmonary function and certain gastrointestinal diseases including cirrhosis. This review includes practical approaches to each of these conditions with attention to risk assessment and avoidance, vaccination when appropriate and not a risk to the compromised host, and arming the traveller with self-therapy and chemoprophylaxis. Since travellers with underlying conditions are often taking various medications the travel health practitioner must be alert for possible drug/drug interactions and must adjust dosages depending on the level of compromised renal or hepatic function. Finally, education of such travellers is paramount; they must understand that risk avoidance is critical and preventative modalities such as vaccination and chemoprophylaxis are never 100% efficacious.

Imbalance in the expression of CXC chemokines correlates with bronchoalveolar lavage fluid angiogenic activity and procollagen levels in acute respiratory distress syndrome.

Diffuse alveolar damage is the histopathological hallmark of acute respiratory distress syndrome (ARDS) and is a stereotypic response to a variety of etiologies. Moreover, a significant proportion of ARDS survivors have residual pulmonary fibrosis and compromised pulmonary function. This suggests that the pathogenesis of diffuse alveolar damage that ultimately leads to the chronic fibrosis of ARDS has features of dysregulated repair exemplified by exaggerated intra-alveolar angiogenesis and fibrogenesis (i.e., fibroproliferation and deposition of extracellular matrix), leading to progressive alveolar fibrosis and impaired lung function. We obtained bronchoalveolar lavage fluid (BALF) from patients with ARDS or ventilated control patients and assessed CXC chemokine levels by ELISA. We found an imbalance in the expression of ELR(+) as compared with ELR(-) CXC chemokines from BALF of patients with ARDS as compared with controls. This imbalance correlated with angiogenic activity as assessed by the corneal micropocket assay. Furthermore, these levels correlated with both procollagen I and procollagen III levels in BALF. In contrast, while BALF levels of vascular endothelial growth factor were elevated, vascular endothelial growth factor did not appear to be significantly contributing to the angiogenic activity. These findings suggest that CXC chemokines have an important role in the fibroproliferative phase of ARDS via the regulation of angiogenesis.

Involved-field radiotherapy alone for early-stage non–small-cell lung cancer

Purpose: To describe the outcome of involved-field radiotherapy in patients with early-stage non–small-cell lung cancer (NSCLC). Methods and Materials: A written policy for the radical treatment of early-stage NSCLC with involved-field radiotherapy was adopted at our center in 1986. The sites of known disease were treated to a dose of 52.5 Gy in 20 daily fractions over 4 weeks without elective irradiation of radiologically uninvolved regional nodes. We have reviewed the outcome of this policy in 102 patients treated with radiotherapy alone between 1986 and 1995. Results: The patients’ median age was 71.5 years. The stage distribution was as follows: T1, 33.3%; T2, 56.9%; T3, 8.8%; and T4, 1.0%. Only 5 cases were N1; the remainder were N0. Most patients (76.5%) were not surgical candidates because of co-morbidity. Ninety-three percent had a CT of the thorax as part of their initial staging, while mediastinoscopy was performed in only 16.7%. Overall survival was 35% at 3 years and 16% at 5 years. Recurrence free survival was 23.9% at 3 years and 13.9% at 5 years. Cause-specific survival was 43.5% at 3 years and 26.8% at 5 years. Of those who recurred, 68.9% had a local component of failure at initial relapse, and 49.2% failed locally without evidence of regional or distant metastases. Isolated regional nodal relapse at initial failure occurred in only 6.6% of recurrences. There were no treatment interruptions due to acute toxicity and no treatment-related deaths. Conclusion: Involved-field radiotherapy alone cures a small but significant number of patients with early-stage NSCLC. This approach is recommended in patients who are unfit for surgery and who have severely compromised pulmonary function that would preclude the use of wide-field radiotherapy. The dose used in this study was well tolerated, but produced suboptimal local control rates.

Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the oesophagus.

The outcome after oesophagectomy depends not only on the surgical procedure itself but can be improved by the selection of patients based on a preoperative risk score. In order to compare the preoperative risk for different histological subtypes of oesophageal carcinoma, 221 patients with a squamous cell carcinoma (SCC) and 104 patients with an adenocarcinoma (AC) were enrolled in a prospective study. The preoperative assessment included socioeconomic status, alcohol and tobacco consumption, general and nutritional status, and pulmonary, cardiovascular, hepatic and renal function. More patients with an SCC were 'blue collar' and with an AC were 'white collar' workers (P < 0.001). Alcohol and tobacco consumption was higher in patients with an SCC (P < 0.01 and P < 0.05 respectively). The preoperative forced expiratory volume, arterial partial pressure of oxygen and the aminopyrine breath test showed more severely compromised pulmonary and hepatic function in patients with an SCC (P < 0.05 for all variables). Some 50 per cent of patients with an AC were overweight with a higher body mass index (P < 0.001). More patients with an AC had severely impaired cardiac function (P < 0.01). Patients with SCC and AC of the oesophagus differed regarding their socioeconomic and preoperative risk factors for surgery.

Long-term results of sleeve lobectomy for lung cancer

Sleeve lobectomy is a lung saving procedure indicated for central tumors for which the alternative is a pneumonectomy. Current controversies relate to the safety of the procedure and adequacy as a cancer operation. The aim of the study is to analyze long-term survival after sleeve lobectomy, particularly in relation with nodal status and histological type. The incidence and patterns of recurrences were reviewed. From 1972 to 1998, 184 patients (male 152, female 32) underwent sleeve resection for lung cancer. The mean age was 60+/-10 years (11-78 years), and the indications for operation were a central tumor (79%), peripheral tumor with nodal involvement (13%) and compromised pulmonary function (8%). The histological type was predominantly squamous (n=125, 68%), followed by non-squamous (n=50, 27%) and carcinoid tumors (n=9, 5%). Resection was complete in 161 patients (87%). The operative mortality was 1.6% (n=3). Follow-up was complete for the remaining 181 patients (mean, 5.7 years; range, 1 month-26 years). The survival at 5 and 10 years of all patients was 52 and 33%, respectively. Theses rates for patients with N0 status (n=97) were 63 and 48%, and 48 and 27% for those with N1 status (n=68; N0 vs. N1, P<0.05). An 8% survival rate was observed with N2 status (n=19) at 5 years, with no survivors after 7 years of follow-up. The 5 and 10 year survival was 56 and 34% for squamous carcinoma vs. 33 and 22% for non-squamous carcinoma (P<0.05). These rates were 58 and 38% for complete resection vs. 11 and 6% for incomplete resection at 5 and 10 years, respectively (P<0.05). Local recurrences occurred in 22% of cases, and the prevalence was statistically different between patients with N0 disease (14%) and N1 disease (23%; P=0.03), but not between N1 and N2 disease (42%; P=0.2). When local and distant recurrence were pooled together, the differences were highly significant between N0 (22%) and N1 (41%) disease (P=0.007), and between N0 and N2 (63%) disease (P=0.0002), but not between N1 and N2 disease (P=0.09). Sleeve lobectomy is a safe and effective therapy for patients with resectable lung cancer. The presence of N1 and N2 disease, or of non-squamous carcinoma significantly worsen the prognosis.

Orthopedic management of neuromuscular disorders in children

In many cases, the orthopedic surgeon may be the first consultant requested to assess complaints of lower extremity weakness or deformity to result from such conditions and must remain alert to the primary diagnosis. In addition, the orthopedic surgeon should be prepared to guide appropriate physical therapy, prescribe orthotics, and perform surgery to improve function, prevent deformity, or provide comfort when necessary. Most deformities of the extremities result from a combination of muscle weakness and imbalance, and surgical procedures are aimed at correcting existing deformity and rebalancing existing musculature by release or transfer. Skeletally immature patients with neuromuscular disorders are also susceptible to the development of scoliosis, which may impair comfortable sitting or already compromised pulmonary function. This article reviews the clinical manifestation and orthopedic management of Duchenne's muscular dystrophy, spinal muscular atrophy, facioscapulohumeral dystrophy, and Charcot-Marie-Tooth disease.

Periodical Multiphasic Screening and Lung Cancer Prevention

The purpose of this work is to evaluate the utilization of information gathered by multiphasic screening with respect to lung cancer detection and smoking cessation techniques. A cohort (follow-up) study is reported in which cancer incidence and factors affecting its occurrence are evaluated in a group of about 20,000 presumably healthy adults along a period of approximately 10 years following comprehensive multiphasic health examinations. Lung cancer occurrence is primarily related to smoking. The risk is higher in smokers and is dose-dependent; OR = 0.21, (CI = 0.08, .53) in never smokers, OR = 1.53 (CI = 0.8, 3.2) in past and current moderate smokers, OR = 4.92 (CI = 2.18, 11.11) in current heavy smokers. Moreover, smokers with compromised pulmonary function (FEVI/FVC < 75%) are at an even higher risk of developing lung cancer OR = 4.22 (CI = 2.2, 8.2) for past and current moderate smokers; and OR = 10.7 (CI-2.5, 38.6) in current heavy smokers. Information gathered in periodical multiphasic health examinations could be utilized by health professionals to encourage smoking cessation and smoking prevention in the appropriate screenees. Various elements of the multiphasic test results could contribute to such prevention efforts. While every smoker should receive appropriate evaluation and consultation regarding nicotine dependence, smokers with reduced pulmonary function represent an extra high risk group to which special attention should be given.

The synergy of low lung function and low body mass index predicting all-cause mortality among older Japanese-American men.

To assess the joint characteristics of low standardized weight and compromised pulmonary function in predicting all-cause mortality. A population-based, prospective cohort study. Oahu Island, Hawaii. Surviving Japanese-American men of the Honolulu Heart Program cohort, 71 to 93 years of age (N = 3059). Body mass index (BMI-weight in kilograms/square of height in meters) and 1-second forced expiratory volume (FEV1) as a percentage of age- and height-predicted FEV1 from the 1991 to 1993 examination of the cohort. Mortality data derived from the ongoing tracking of deaths of the cohort. Relations of selected risk factors among joint levels of BMI (< or = 21, > 21 to < 25, > or = 25 kg/m2) and percent predicted FEV1 (< or = 70%, > 70%) were determined. The impact of these covariates on relations between joint BMI/percent predicted FEV1 levels and subsequent all-cause mortality was assessed. The highest age-adjusted mortality rate (91.9 deaths per 1000 person-years) was noted among men characterized by the joint conditions of percent predicted FEV1 < or = 70% and BMI < or = 21 kg/m2. This rate was 4.0 times the mortality rate of a "healthy" reference group characterized by percent predicted FEV1 > 70% and 21 < BMI < 25 kg/m2. This rate ratio is attenuated to 3.2 upon statistical control for measures of current and past smoking behavior. Among the three strata of BMI, statistical interaction is reflected in a heterogeneity of mortality rate differences (49.7, 21.8, -9.6 deaths/person-year, respectively) and rate ratios (2.18, 1.98, .66, respectively) comparing men with percent predicted FEV1 < or = 70% to > 70%. Joint loss of pulmonary function and relative weight is predictive of subsequent all-cause mortality in excess of additive or multiplicative effects of each condition separately. Smoking behavior may contribute to this observation.

Impact of the hypothermic response in inhalation toxicology studies.

Previous studies from this laboratory showed that the decreases in Tco and associated functional parameters often observed in rodents following exposure to xenobiotic agents are capable of modulating the subsequent toxic response and that the magnitude of this induced hypothermic response may itself be modified by a number of experimental conditions. A moderate hypothermic response, characterized by a temperature drop of approximately 2 degrees C, appears to afford the optimal protection. Studies in which exposures occur through inhalation of harmful gases or particles present a special set of problems. In such studies, the dose of the toxic agent to which the animal is exposed is a function of the concentration of the agent in the atmosphere and the minute ventilation of the animal. Although ambient concentrations is generally held constant in laboratory studies, minute ventilation varies directly with metabolism, and both of these parameters may change significantly across experimental conditions. Thus, at low Tas, metabolism and minute ventilation are relatively high and uptake of inhalable toxic agents is increased. However, the development of the hypothermic response during the exposure entails a directly correlated reduction in these parameters and, presumably, in dose. For the most part, inhalation toxicological studies are conducted using resting animals or exercising humans. Animals are sometimes concurrently exposed to CO2 to simulate the increased ventilation of exercise and more closely mimic human studies. The experimental protocols employed in the above inhalation studies permitted examination of (1) the impact of species, size, handling stress, and changes in Ta on both the induced hypothermic response and the concomitant pulmonary toxicity; (2) the additive impact of exercise stress on O3 toxicity; and (3) the toxicity of ambient-derived particulate matter in normal rats and in rats with preexisting pulmonary inflammation. The results of these studies demonstrate that the magnitude of the induced hypothermic response is directly proportional to the uptake of the toxic agent by the lung and inversely proportional to the mass of the animal and the ambient temperature at which the exposure is conducted. The hypothermic response is sensitive to a number of experimental stresses including handling and changes in cage conditions. Exercise attenuates the hypothermic response, whereas CO2-stimulated increases in ventilation employed as an exercise surrogate may potentiate the response. Toxic exposures conducted in animals with lung disease or compromised pulmonary function may induce a severe hypothermic response while comparable exposures in normal animals produce only mild or moderate responses. In general, the development of the hypothermic response in the presence of ambient pollutants serves to decrease the minute ventilation of the animal and therefore limits the uptake and dose of the airborne toxicant. The results of these inhalation studies support our previous conclusions concerning the impact of the hypothermic response on toxicity and emphasize the need to monitor and incorporate these changes in functional parameters into analyses of toxicological data. Furthermore, because humans do not demonstrate a robust hypothermic response following exposure to toxic agents, extrapolation of the results obtained from animal studies and comparisons with data from human studies are considerably more complicated.

Cardiopulmonary aspects of laparoscopic surgery

Intra-abdominal gas insufflation used during laparoscopic surgery causes adverse circulatory and respiratory effects. This can be hazardous for patients with compromised cardiac or pulmonary function or both, and there is an increased awareness of the intra-operative risks during laparoscopy. Recent studies indicate that there is a potential for pharmacological treatment of circulatory abnormalities during laparoscopic surgery, possibly enabling even compromised patients to benefit from the postoperative advantages of the technique. The recent development of methods for gasless laparoscopy also reflects the urge for less cardiopulmonary side effects of the laparoscopic technique.

Lung resection in patients with compromised pulmonary function

Some patients are denied curative pulmonary resection for lung carcinoma because of pulmonary insufficiency. To identify factors that affect postoperative morbidity and mortality, we reviewed 85 consecutive patients (53 men and 32 women) with a preoperative forced expiratory volume in 1 second of less than 1.2 L who underwent pulmonary resection for lung cancer between January 1986 and December 1990. Median age was 70 years (range, 49 to 82 years). Sixty patients (71%) had been previously denied operation because of pulmonary insufficiency. Preoperative pulmonary function demonstrated a median preoperative forced expiratory volume in 1 second of 1.0 L (44% of predicted normal; range, 0.5 to 1.2 L) and a diffusing capacity of the lung for carbon monoxide of 60% of predicted normal (range, 22% to 104%). Pneumonectomy was done in 6 patients (7.1%), bilobectomy in 6 (7.1%), lobectomy in 38 (44.7%), segmentectomy in 12 (14.1%), and wedge excision in 29 (27.1%). The median predicted postoperative forced expiratory volume in 1 second was 0.83 L (34% of predicted normal; range, 0.45 to 1.14 L), and the median predicted postoperative diffusing capacity of the lung for carbon monoxide was 48% of predicted normal (range, 19% to 87%). Seventy-two patients (85%) received postoperative epidural analgesia. Median hospitalization was 15 days (range, 5 to 66 days). Operative mortality was 2.4%, and complications occurred in 49%. We did not identify any factors that predicted postoperative morbidity and mortality. Median follow-up was 3.2 years (range, 0.2 to 9 years). Seven patients (8%) required supplemental home oxygen. A predicted postoperative percent forced expiratory volume in 1 second less than 43% correlated with the need for home oxygen (p < 0.05). Overall 5-year survival was 44.0%. Survival for stage I cancer was 54.2%; stage II, 33.1%; and stage IIIa, 21.3%. We conclude that some patients with lung cancer and compromised pulmonary function can safely undergo pulmonary resection if selected appropriately.

Evaluation of deformities and pulmonary function in adolescent idiopathic right thoracic scoliosis.

Seventy patients with adolescent idiopathic right thoracic scoliosis had full assessment of their pulmonary function using a computerised pulmonary function system. Their mean age at evaluation was 13.8 years. The following measurements were obtained from anteroposterior and lateral standing and antero-posterior supine bending radiographs: lateral curvature, vertebral rotation, kyphosis, maximum sterno-vertebral distance and apical rib-vertebral angles. Using the above measurements, the flexibility of curve, vertebral rotation and rib-vertebral angle asymmetry were calculated. Patients were classified into three groups on the basis of their predicted vital capacity, to determine whether radiological features of deformity can help identify patients with compromised pulmonary function. The mean Cobb angle and vertebral rotation for the 70 patients were 50 degrees (range 35-100 degrees) and 22 degrees (range 1-44 degrees) respectively. The mean flexibility of curve and vertebral rotation were 52% and 49% respectively. Mean thoracic kyphosis was 25 degrees, ranging from -7 to 55 degrees. Of the patients with Cobb angle less than 90 degrees, 71% had vital capacity less than 80% of predicted values, and of these, 18% had marked compromise of vital capacity (less than 60% of predicted values). Mean values of Cobb angle, vertebral rotational flexibility, kyphosis, rib-vertebral angle asymmetry (in standing as well as supine bending radiographs) differed significantly between patients with more than 80% of predicted vital capacity and those with 60% or less of predicted values. Radiological features indicative of better pulmonary function were: rotational flexibility exceeding 55%, rib-vertebral angle asymmetry (standing) less than 25 degrees and kyphosis greater than 15 degrees. Two deformity parameters--that give a better prediction of pulmonary function than the widely used Cobb angle, vertebral rotational flexibility and rib-vertebral angle asymmetry--were identified in this study.