Copious Sputum Research Articles

Clinical characteristics of 32 cases of diffuse panbronchiolitis.

Diffuse panbronchiolitis (DPB) is a chronic airway inflammation with low specificity and its diagnosis is often missed or delayed. This study aims to summarize the clinical characteristics and treatment of DPB in order to improve the understanding and diagnosis of the disease. The clinical data of 32 DPB patients were collected, analyzed and summarized from March 1, 2013 to March 1, 2022 in the Second Xiangya Hospital of Central South University. The basic information, clinical manifestations, laboratory tests, pulmonary function, imaging tests, treatment, and regression of patients were analyzed. A total of 32 patients were enrolled in the final analysis, with a male-to-female ratio at 1.67. The median age at symptom onset was 26.5 (11.0-69.0) years, and the median age of diagnosis was 47.5 (16.0-77.0) years. All patients presented with chronic cough and copious sputum production. A total of 26 patients had post activity shortness of breath and 14 patients had a positive result (blood cold agglutination test titer≥1꞉64). Pulmonary function examination was performed in 31 patients, 18 patients showed mixed pulmonary ventilation dysfunction, 12 patients showed obstructive pulmonary ventilation, and 1 patient had normal pulmonary ventilation function. A total of 31 patients had a bilateral, diffuse, small nodule pattern on chest CT. All patients were treated with macrolides. A total of 31 patients showed improvement, and 20 patients showed improvement in partial pressure of oxygen and blood oxygen saturation compared with before at discharge. A total of 12 patients were re-examined by chest CT after completing macrolides treatment, 6 cases showed less diffuse nodules, 5 cases showed no significant changes, and 1 case showed more diffuse nodules, which indicated the disease progression. Seven patients received pulmonary function tests after completing macrolides treatment, forced expiratory volume in one second (FEV1) and FEV1/forced vital capacitywere improved, but forced expiratory flow at 25% of vital capacity did not change significantly. The clinical manifestations of DPB are nonspecific. Early diagnosis and treatment are very important for the prognosis of patients.

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment.

Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship. A discrete choice experiment presented participants with a vignette consisting of the same "stem" plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3-4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute. The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States. In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99-1.3), hypotension (utility, 0.88; 95% CI, 0.74-1.03), fever (utility, 0.76; 95% CI, 0.62-0.91) and copious sputum (utility, 0.75; 95% CI, 0.60-0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17-0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05-0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate. Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.

Comparison of Head-Down Tilt versus Flat Position on Mucus Clearance and Respiratory Mechanics in Mechanically Ventilated Patients: A Randomized Crossover Trial

Background: Most of the mechanically ventilated patients in the intensive care unit have impaired bronchial mucociliary transport and copious sputum production due to abnormal cilia function. This leads to pulmonary complications such as lung collapse, pulmonary infection, and hypoxemia. Objective: This study was designed to compare the effects of a head-down tilt position and a flat position in improving mucus clearance and respiratory mechanics in mechanically ventilated patients. Materials and Methods: This was a randomized crossover study in which 24 patients with 17 males and 7 females were randomly allocated to one of two treatment sequences over 2 days. The sequence involved head-down tilt position followed by 4 hours later, a flat position, and the order was reversed on the second day. Chest physiotherapy techniques were given in each position on both consecutive days. In the second sequence, a supine position preceded the head-down tilt position. Measurement of sputum was taken postintervention in each place on day one and day two. Analyses of respiratory mechanics (static compliance, dynamic compliance, and resistance) were made at baseline, immediately postintervention, and 30 minutes postintervention. A paired ttest was used to compute the differences in sputum volume. Two way repeated measures analysis of variance (ANOVA) was used to calculate the differences in respiratory mechanics. Statistical significance was set at p < 0.05. Results: A head-down tilt position produced more sputum than a flat position immediately after chest physiotherapy techniques (p < 0.05). Static and dynamic compliance improved immediately following chest physiotherapy techniques (p < 0.05). Conclusion: A head-down tilt position can be recommended over the a flat position in improving mucus clearance and respiratory mechanics in mechanically ventilated patients

The development of diffuse panbronchiolitis during the treatment with long-term, low-dose clarithromycin for chronic sinusitis

Diffuse panbronchiolitis (DPB) is a progressive inflammatory airway disease characterized by a chronic cough, copious sputum expectation, dyspnea, and chronic sinusitis. Owing to the long-term treatment of low-dose macrolides, the prognosis has been remarkably improved. However, in some cases, patients are refractory to macrolides, and the subsequent treatment strategies are controversial. We herein present a patient with the onset of DPB during treatment with long-term, low-dose clarithromycin (CAM) for chronic sinusitis who was successfully treated by switching to long-term treatment with normal-dose CAM. We should recognize that DPB may develop in patients with chronic sinusitis despite treatment with a long-term, low-dose macrolide. We also propose that increasing the dose of macrolide may be a useful strategy for treating refractory patients.

Nutritional Supplement "Bao Khi Khang" as an Adjuvant Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

To investigate the effectiveness of nutritional supplement Bao Khi Khang as an adjuvant therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD) compared to conventional therapy alone. This was a prospective, randomized, open-label controlled trial in 60 patients presenting with acute exacerbation of COPD. Patients were randomized into two groups, the control and the experimental groups. The control group was treated with the standard therapeutic protocol (Antimicrobial+Corticosteroids+Bronchodilator+Mucolytic drugs). The experimental group was treated with Bao Khi Khang tablets combined with the standard therapeutic protocol. The treatment outcomes, including clinical and paraclinical parameters of exacerbation of COPD, were compared between the experimental group and the control group at day 15 and 30. This study was conducted according to protocol: 01.2014-HTNCKH. The results showed a significant reduction of major COPD exacerbation symptoms in experimental group. The favorable progresses in mMRC scale and COPD Assessment Test score before and after treatment, between experimental group and control group, were statistically different. Symptom control such as cough, copious sputum secretion, and bacterial infection was 90% effective (very good 50.0%, good 40.0%) in experimental group compared to 50% (very good 20%, good 30.0%) in control group. No adverse side effects were observed in experimental group. Bao Khi Khang nutritional supplement could be an effective and safe adjuvant therapy in acute exacerbations of COPD. Further interventional studies are required to confirm these findings.

Impact of upper respiratory tract infections on perioperative outcomes of children undergoing therapeutic cardiac catheterisation.

Recent upper respiratory tract infection (URI) is associated with increased incidence of perioperative complications in children undergoing open heart surgery. As a result, surgery is often postponed. However, the effect of recent URI on the incidence of perioperative complications in children undergoing therapeutic cardiac catheterisation is unknown. We investigated the perioperative outcomes of congenital heart disease (CHD) children with recent URI who underwent elective therapeutic catheterisation. We prospectively included children treated for CHD. Before surgery, parents or legal guardians were interviewed to complete a questionnaire on the child's demographics, history of asthma and passive smoking, and URI symptoms. Recorded perioperative respiratory adverse events (PRAEs) included laryngospasm, bronchospasm, breath holding, oxygen desaturation, and severe cough. Information on postoperative dysphoria, fever, copious sputum, and vomiting was obtained by telephone 24 h after surgery. Of 363 included children, 169 had recently (within 2 weeks) had a URI. The URI did not affect the incidence of laryngospasm, bronchospasm, breath holding, fever, or vomiting. The incidence of desaturation, severe cough, dysphoria, and copious sputum were significantly increased. Independent risk factors for PRAEs in children with a recent URI included age, passive smoking, and presence of rhinorrhoea or moist cough. The lengths of stay in the hospital and intensive care unit were not significantly different between groups. Although recent URI increased the incidence of PRAEs in children undergoing therapeutic cardiac catheterisation, most CHD patients with recent URI can undergo elective therapeutic cardiac catheterisation without serious adverse events or prolonged hospitalisation.

Surgical management of bronchiectasis

Background: Bronchiectasis is the permanent dilatation of the bronchi due to destruction of bronchial wall. Bronchi­ectasis still remains a serious problem in developing countries despite of modern medical facilities.Objectives: This study aims to demonstrate our surgical experience for bronchiectasis and analyze the risk factors related with the surgery outcome.Methods: Hospital based analyses of 39 patients were done who were underwent surgery for bronchiectasis and were on follow up in National Institute of Diseases of Chest hospital (NIDCH) in September 2014 to February 2015 were included in this study. All 39 patients had surgery for the bronchiectasis in the period of January 2014 to December 2014.Results: The mean age of the patients were 22.2 years. Twenty four patients were females and 15 were male. Symptoms were recurrent infection with cough, copious sputum in all patients and hemoptysis in 31 patients. The etiology was recur­rent childhood infection in 17 patients, pneumonia in 11 patients, PTB in 6 patients, Aspiration in 2 patients, foreign body obstruction in 1 patient, and unknown etiology in 2 patients. Chest x-ray, CT scan and rigid bronchoscope were done for all patients. Bronchiectasis was left-sided in 17 patients. It was mainly confined to the lower lobes either alone in 9 patients and in conjunction with middle lobe or lingual in 8 patients. Indications for resection were failure of conservative therapy in 22 patients, hemoptysis in 8 patients, destroyed lung in 9 patients. Surgery was lobectomy in 24 patients, Bilobectomy in 5 patients, and pneumonectomy in 10 patients. Complications occurred in 10 patients with no operative mortality. Thirty four patients had relief of their preoperative symptoms after surgery in follow up periods.Conclusions: Surgical resection for bronchiectasis should be reserved for patients with localised disease who have failed medical management and have persistent symptoms that negatively affect their quality of life.

Cyst in the Liver and Cough with Copious Purulent Sputum

Cyst in the Liver and Cough with Copious Purulent Sputum

Evaluation by survival analysis on effect of traditional Chinese medicine in treating children with respiratory syncytial viral pneumonia of phlegm-heat blocking Fei syndrome

To objectively evaluate the clinical effect of traditional Chinese medicine in treating children's respiratory syncytial viral pneumonia (RSVP) of phlegm-heat blocking Fei syndrome (PHBFS). A single-blinded multi-center, blocked, randomized and parallel-controlled method was adopted. The clinical study was carried out on 206 children with RSVP-PHBFS who were assigned to two groups, 108 in the test group treated through intravenous dripping of Qingkailing Injection () in combination of oral intake of Er'tong Qingfei Oral Liquid () and 98 in the control group with intravenous dripping of ribavirin injection in combination with oral intake of potassium guaiacol sulfonate oral liquid, all for 10 days. The clinical efficacy was evaluated and compared at the end of the trial from various aspects by three methods including comprehensive efficacy, post-treatment main symptoms score difference and survival analysis of the main symptoms. After treatment, in the test group, 60 patients were cured, 36 markedly alleviated, and 12 improved. In the control group, 41 were cured, 38 markedly alleviated, 18 improved and 1 unchanged. Comparison on the comprehensive efficacy between the two groups shows a better efficacy in the test group (chi(2)=4.4527, P=0.0348). Scores of the main symptoms were lowered after treatment in both groups, the difference was 22.41+/-4.99 scores in the test group and 17.61+/-6.34 scores in the control group, being more significant in the former (t=-5.99, P<0.01). Survival analysis shows that there was significant difference between the two groups in the effect initiating time on such symptoms as fever, cough, copious sputum, shortness of breath, and rales, which was earlier in the test group (P<0.01 or P<0.05). Evaluation of the efficacy of traditional Chinese medicine in treating children with RSVP-PHBFS by using the three methods jointly could better show the objectivity of the evaluation.

Exacerbation of Asthma by Florida “Red Tide” During an Ocean Sailing Trip

A 36-year-old man with adult-onset nonallergic triad asthma developed acute bronchospasm and copious sputum production during an offshore sailing excursion on the Gulf Coast of Florida. Symptoms were linked to proximity to blooms of the marine dinoflagellate Karenia brevis (red tide) and heavy aerosolized brevetoxin exposure, and symptoms recurred during rechallenge. Patients with respiratory disease who are planning a visit to red tide-prone seaside areas should be cautioned to bring their pulmonary medications, and clinicians should be aware that reactive airway symptoms may be triggered by exposure to red tide.

Concept and use of the guidelines

Cough is one of the most frequent complaints for which patients seek medical care throughout the world.1 The exact prevalence of cough in Japan is unknown, but in the UK, 10–15% of the entire population have a daily cough,2 and in the USA, over 100 million dollars are spent each year on treatment of cough.3 The aetiology of cough ranges from the self-resolving common cold to life-threatening cardiac disease and lung cancer. Even if the underlying disease has a good prognosis, the energy expended due to cough decreases patient quality of life (QOL). In addition to being a discomfort for patients, cough due to severe acute respiratory syndrome (SARS) and tuberculosis spreads the risk of infection to family, friends and associates. The presence of rhonchi or rales on physical examination or abnormal findings on CXR makes the diagnosis of cough relatively easy, but in the absence of these findings, many patients may complain of a cough for several weeks without a diagnosis. A recent increase in patients with unexplained cough has been noted both by generalists and specialists in pulmonary medicine. Physicians often focus on symptomatic treatment of cough, but suppression of a productive cough with copious sputum production or cough due to aspiration may worsen the patient’s condition.4 For this reason, the Japanese Respiratory Society has decided to publish the ‘Cough Guidelines’. These guidelines broadly define cough based on duration as acute cough lasting less than 3 weeks, prolonged cough lasting 3–8 weeks and chronic cough lasting longer than 8 weeks. The guidelines are also divided into general and special topics. The special topics include acute cough, prolonged and chronic cough and cough in specific populations (paediatric patients, elderly patients and patients with underlying disease). The authors include paediatricians, internists and ENT specialists. Figure 1.1 shows the incidence of aetiology of cough for each period defined in the guidelines. The most common cause of acute cough is respiratory tract infection, whereas prolonged and chronic coughs of longer duration are more likely due to a non-infectious cause. A consensus report on cough published in the USA has been used in Japan, but many clinicians believe that underlying disease prevalence differs between patients with cough in Japan and Western countries.5 For example, of the three main causes of chronic cough in Western countries,5 cough-variant asthma, postnasal drip and gastro-esophageal reflux disease (GERD), the latter two are not as prevalent in Japan. Duration of symptoms and incidence of cough due to infection. Therefore, these guidelines are not necessarily based on reports from Western countries, but are rather designed specifically for Japan. Cough is a common symptom, and the true value of these guidelines is that they are intended not only for pulmonary specialists, but also for the many generalist physicians who provide front-line care for most of these patients. For disorders presenting with persistent or chronic cough, these guidelines offer both simplified diagnostic criteria that can be used in general clinics where special tests are not needed, as well as more stringent diagnostic criteria requiring special tests that can only be performed in larger general or university hospitals with departments of pulmonary medicine. These guidelines are aimed at the differential diagnosis and treatment of common disorders seen in clinical practice. They are not all-inclusive of some rarer diseases usually found only in textbooks. These guidelines do not limit or impose specific treatment recommendations. We have written these guidelines based on the most reliable data currently available, but in some cases a better means of diagnosis or treatment may be available. We welcome comments and suggestions from those using these guidelines to make future editions more relevant and useful. Our intent is to improve QOL in the many patients who suffer from cough.

Relation of Epidermal Growth Factor Receptor Expression to Goblet Cell Dysplasia in Diffuse Panbronchiolitis

Background: Diffuse panbronchiolitis(DPB) is a chronic inflammatory lung disease that presents as coughing, copious sputum, exertional dyspnea, which progresses to bronchiectasis. The pathogenesis of bronchiectasis is controlled by inflammatory mediators, which are closely related to mucus hypersecretion, goblet cell dysplasia. In recent studies, the epidermal growth factor receptor(EGFR) system was reported to be associated with this process. It was hypothesized that a relationship exists between goblet cell dysplasia, EGFR expression, and inflammatory mediators produced by neutrophil. Method: Alcian blue/periodic acid -Schiff(AB/PAS) stain, MUC5AC, EGFR, CD16 immunohistochemical stain were examined to investigate a role for the EGFR system in a mucus hypersecretion in DPB using the lung biopsy specimens from 13 DPB patients and 6 controls. Results : In the DPB group, the AB/PAS and MUC5AC -stained areas were , , respectively. In the control group, the AB/PAS- and MUC5AC-stained areas were , , which was significantly larger than in the DPB group (each comparison, p in the DPB group, but zero in of the control group. The extent of neutrophilic infiltration was /5HPF in the DPB group and /5HPF in the control group, which was statistically significant(p=0.002). Conclusion: The EGFR system is highly related to goblet cell dysplasia, mucus hypersecretion and neutrophilic inflammation in DPB.

Evaluation of chest percussion in the treatment of patients with copious sputum production

The effect of manual chest percussion was studied in nine patients with copious sputum production. Treatment consisting of postural drainage (PD) and the forced expiration technique (FET) produced sputum at the rate of 0.831 g min-1. When percussion was included in the treatment regimen, the rate of sputum production was significantly greater (P less than 0.05), being 1.231 g min-1 for fast percussion and 1.040 g min-1 for slow percussion. Pulmonary function and oxygen saturation were unaffected by any of the treatment regimens. This study demonstrates that manual chest percussion is a useful adjunct to PD and FET in the treatment of patients with copious sputum production.

NOSOCOMIAL BACTERIAL EYE INFECTIONS IN INTENSIVE-CARE UNITS

A cluster of ten nosocomial eye infections occurred in three intensive-care units during an 18-month period. Nine of the ten patients were intubated, all were obtunded, and all had copious sputum production. The bacteria isolated from the patients' sputum samples and from the eyes were identical in nine cases. Pseudomonas aeruginosa caused six of the infections, including all those with complications (three corneal ulcers, two hypopyon, one opaque cornea, two corneal rupture). Three patients lost their sight. Only the left eye was infected in nine cases. In a prospective study of bacterial dispersion during tracheal suctioning of twenty intubated patients, patients with copious secretions had significantly higher bacterial colony counts on settle plates than those without. Colony counts were higher on the side opposite to the hand the nurse used to withdraw the catheter than on the same side. Nurses tended to withdraw the catheter diagonally across the patient's face, which may explain the selective involvement of the left eye.

Endobronchial Malignant Lymphoma: Unusual Manifestations — A Report of Two Cases —

Two unusual manifestations associated with endobronchial malignant lymphoma are reported. A 58-year-old white female was first seen with massive hemoptysis requiring blood transfusion and pneumonectomy for histiocytic lymphoma (large cell type). The second case was that of a 47-year-old black male treated previously for poorly differentiated lymphocytic lymphoma (medium-sized cell type) who had a relapse in the lungs. Increasingly copious sputum production led to respiratory distress which required extensive radiation therapy and chemotherapy for its control.

Widened Superior Mediastinum With Acute and Chronic Pulmonary Symptoms

History A 28-year-old black man had a history of chest pain, fever, and a severe cough with purulent sputum for seven days. He had been coughing for several years and during this period had always produced copious sputum, with a single episode of hemoptysis in the past. He had been hospitalized with pneumonia one year previously but had made a quick recovery after receiving appropriate therapy. Physical examination showed mild dyspnea and clubbing of the fingers. Signs of pneumonic consolidation were present at the right base, and there were scattered rhonchi throughout his chest. He was not cyanotic, and posteroanterior and lateral chest roentgenograms were obtained (Fig 1 and 2). Diagnosis Tracheobronchomegaly: the Mounier-Kuhn syndrome. Comment The frontal chest roentgenogram (Fig 1) shows a widened superior mediastinum, initially thought to be due to enlarged glands. However, the lateral projection (Fig 2) confirms that all this shadowing is due to enlarged

Effects of sputum on pulmonary function.

The specific airways conductance (SGAW) of 23 patients with copious sputum production and airflow obstruction was measured before and after physiotherapy to determine the effect of bronchial secretions on pulmonary function. Chest physiotherapy to remove these secretions had the effect of reducing airflow obstruction, as measured by SGAW. These findings suggest that sputum has a detrimental effect on pulmonary function and that physiotherapy can reduce airways obstruction.

The effect of chest physiotherapy upon the FEV1 in chronic bronchitis.

Chest physiotherapy, including posturing the patient head downwards while the chest is percussed and vibrated, was used in the treatment of patients with an exacerbation of chronic bronchitis. In seven patients the mean FEV declined from 1.38 litres plus or minus 0.39 to 1.25 litres plus or minus 0.37 after postural drainage and percussion (P less than 0.001). Twenty minutes later the FEV rose to 1.37 litres plus or minus 0.33. The mean decline in the FEV1 was prevented by prior administration of salbutamol. The fall in the FEV1 did not occur in 10 patients who received the postural tipping without chest percussion. Also it was not induced by coughing every two minutes during posturing. It was considered that the fall in FEV1 after chest physiotherapy was due to bronchoconstriction caused by the chest percussion or vibration, particularly in patients with bronchoconstriction under basal conditions. The induced bronchoconstriction counter-balanced any improvement of the FEV due to freeing the airways of sputum, but in two patients with moderate to copious sputum an improvement of the FEV1 was repeatedly obtained in measurements made 20 minutes after the physiotherapy when the bronchoconstriction had presumably subsided. Although the immediate decline in FEV1 was not large, it is considered inadvisable to employ chest percussion and vibration in sick patients unless a bronchodilator is administered previously.

LOOKING AT PHYSIOLOGY IN THE TREATMENT OF ASTHMA

In this paper, I propose to consider some principles of Physiology in relation to our treatment of the asthmatic child or adult who has suffered the disease for a relatively short time, compared with the adult whose asthma is long standing and who has progressed to some degree of Obstructive Airways Disease. The first is a functional, reversible disease, characterised by episodes of wheeze of varying degree, and with periods of normalcy in between. The second is a structural disease characterised by impairment of activity at all times and the production of copious sputum. This is in itself an irreversible disease but may have an overlying reversible component of varying degree. My recent experience has come from the treatment of out-patients, so that I have not included here treatment for the disabled in-patient with obstructive airways disease, who requires more intensive care.

Emphysematous encephalopathy. Report of a case with abnormal skull roentgenograms.

It is well established that pulmonary insufficiency may be associated with eleva-sion of the cerebrospinal fluid pressure (3). The following case illustrates the syndrome of emphysematous encephalopathy. Skull roentgenograms showed evidence of increased intracranial pressure, a finding not previously reported in pulmonary insufficiency. Case Report On Aug. 30, 1962, this 45-year-old white male was admitted for the fifth time to Montefiore Hospital for control of respiratory and heart failure. Pulmonary disease began at the age of six months when pneumonia complicated pertussis. Frequent attacks of wheezing, productive cough, and pneumonia during childhood and early adulthood culminated in chronic illness when the patient was twenty-seven: dyspnea on exertion, early cyanosis, and cough productive of copious sputum. Symptoms progressed, and at the age of thirty-nine ankle edema, severe orthopnea, chronic cyanosis, and wheezing were noted. On the final admission to Montefiore Hospital the patient presented as a cyanotic, obese white male in severe respiratory distress. He had noted increasing headaches with diminution of memory and concentrating ability. Tachypnea was marked, respiration labored, and neck veins distended. The anteroposterior diameter of the chest was increased. Wheezes were heard diffusely, and subcrepitant râles were noted at both bases. The liver was enlarged 5 cm below the right costal margin. There was 3+ pretibial edema and early clubbing of the fingers. Funduscopic examination showed venous engorgement and papilledema. There were coarse tremors of the hands and striking generalized muscular weakness. The hematocrit was 50 per cent; the white blood cell count and differential were normal. An electrocardiogram was consistent with cor pulmonale with digitaliza-tion effect. Increased cerebrospinal fluid pressure measuring 35 cm of water was demonstrated on lumbar puncture. Roentgenograms are shown in Figures 1 and 2. Pulmonary function studies showed a vital capacity 27 per cent of predicted, a maximum breathing capacity 19 per cent of predicted, and other findings consistent with severe obstructive and restrictive pulmonary disease. CO2 retention with acidosis and oxygen unsaturation were found. The patient died suddenly on the thirty-second hospital day. At postmortem examination the lungs weighed 1,700 g. There were generalized pulmonary emphysema and extensive bronchiectasis of the left lower lobe. Cor pulmonale was present; the heart weighed 850 g and showed dilatation of all chambers; the main pulmonary artery was greatly dilated. Slight flattening of the cerebral sulci indicated cerebral edema. Discussion The neurologic syndrome of headache, muscular weakness, papilledema, drowsiness, and stupor associated with chronic emphysema and other varieties of severe pulmonary insufficiency is well established (1–4) but we have not found it previously reported in the radiologic literature.