Severe Obstructive Pulmonary Disease Research Articles

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.

Pulmonary artery to vein shunts in obstructive pulmonary disease

Forty-six patients with chronic respiratory disease were studied; all but two had obstructive pulmonary disease. In none were intracardiac shunts or pulmonary arteriovenous fistulas detected. In four patients with obstructive pulmonary disease a direct pulmonary artery to vein connection was identified by peripheral pulmonary wedge arteriography. The findings in these four patients (history, physical examination, electrocardiography, chest roentgenography, cardiac catheterization, pulmonary function studies and angiography), compared with those in the remaining patients in whom no shunt was visualized, revealed no discriminating differences. All patients with pulmonary artery to vein connections had moderately severe obstructive pulmonary disease and moderate degrees of pulmonary hypertension. Pulmonary vascular resistance was significantly increased. When measured, the arterial blood pO 2 at the end of a twenty minute period of oxygen breathing was significantly decreased. However, many patients without definitely identifiable shunts showed similar degrees of abnormality. Since many of the latter had arterial blood pO 2 of from 134 to 350 mm. Hg during 100 per cent oxygen breathing, it is likely that arteriovenous shunts were present but not identified by the method of pulmonary arteriography employed.

The Prognostic Value of a Reduced Maximum Breathing Capacity in Tuberculosis

Summary At least 10 per cent of 143 patients hospitalized with tuberculosis had an MBC less than 40 per cent of the predicted normal value. Reductions of the MBC of this degree were generally associated with severe obstructive disease and far advanced tuberculosis. The fatalities in 177 patients with an MBC less than 40 per cent of normal was three times as great as in 185 patients with a normal MBC. In the abnormally low MBC group, mortality was greater in every category of severity of pulmonary tuberculosis than in the normal MBC group. The relationship between obstructive lung disease and pulmonary tuberculosis is discussed. The results indicate that severe obstructive pulmonary disease in patients with tuberculosis considerably worsens their prognosis.

RESPONSES TO EXERCISE TRAINING IN PATIENTS WITH EMPHYSEMA.

The stress imposed by exercise is usually considered deleterious to patients with cardiopulmonary disorders. For this reason limitation of activity is often recommended for patients with chronic obstructive pulmonary disease. However, Barach and associates 1,2 have repeatedly reported a clinical observation similar to ours, that patients with chronic obstructive pulmonary disease who continue to be active remain in relatively better health for a longer period of time than their more sedentary counterparts. Such observations prompted the present study to assess the physiological responses to progressive exercise training. Methods Patients with severe obstructive pulmonary disease and evidence of generalized physical disability were selected for the study. Patients with manifestations of left ventricular disease were excluded. In addition, patients who developed either multiple premature ventricular contractions or marked cyanosis during exercise were not included in the study. These latter excluded patients, subsequently trained while breathing supplemental oxygen, will form the basis of