Biomedical subjects
Publications and source records attributed to J S Putnam.
Care of the patient with tracheostomy is not difficult if care is taken to define clearly the needs of the particular patient. An awareness of the goals of care, daily maintenance, and possible complications is necessary to successful management.
Patients presenting with hemoptysis frequently have a serious underlying disease. Even when the amount of blood is minimal, thorough investigation is indicated. Since many different types of diseases give rise to bleeding from the respiratory tract, a careful and thorough diagnostic evaluation is indicated. Treatment depends upon the cause of the bleeding. Massive hemoptysis is frightening and requires more rapid assessment. When bleeding is considered to be massive, surgical intervention rather than conservative management yields the best chance of survival.
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Twenty-four patients less than 40 years of age were diagnosed at Walter Red Army Medical Center between 1971 and 1976 as having lung cancer. The youngest patient was 19 years old. Only one was a nonsmoker. Most patients were symptomatic at the time of examination. The chest roentgenogram showed an infiltrate or consolidation in 9, a mass lesion in 13, and a pleural effusion in 1. Thirty-eight percent had adenocarcinoma, 21% had squamous cell carcinoma, and 21% large cell carcinoma. Nineteen patients had stage II or III disease at the time of initial examination, and only six had resectable tumors. Survival rates were poor.
Multiple large pulmonary nodules are an uncommon manifestation of sarcoidosis. Cavitation of these nodules has not previously been reported. An asymptomatic young white man had this unusual roentgenographic finding. Open-lung biopsy for diagnosis revealed noncaseating granulomata but did not elucidate the pathogenesis of the cavitation.
Once a diagnosis of COPD is suspected, history, physical examination, pulmonary function tests, chest roentgenogram, sputum analysis, and so forth, are useful to assess the severity of obstructive airways diseases. A comprehensive program of care is then outlined (Table 2). General measures include avoidance of infection and inhalants, humidification, and proper rest and diet. Appropriate medications may include bronchodilators, antibiotics, corticosteroids, cromolyn sodium, digitalis, and diuretics. Inhalation therapy as aerosols, IPPB, and supplemental oxygen may be indicated. Physical therapy with postural drainage, exercise reconditioning, and occupational therapy deserve attention. The day-to-day care of the vast majority of patients with COPD is managed by primary care physicians. This systematic approach to pulmonary rehabilitation will yield definite rewards. Patients will feel and perform better. They will note an improved exercise tolerance, leading to increased activities of daily living. They will experience reduction in the frequency and duration of hospitalization as well as a decrease in anxiety and depression with an improved quality of life.
Applying newer techniques to assess the reactivity of small peripheral airways, we studied the effects of saline and methacholine inhalation in patients with allergic rhinitis. The maximum midexpiratory flow rate (MMF) and the maximum terminal flow (MTF) were used to assess the degree of small airway obstruction. Four rhinitis patients (13 per cent) had abnormal baseline MMF and/or MTF and 12 patients (38 per cent) developed a decrease in MMF and/or MTF after saline inhalation. Twenty-one patients (66 per cent) responded to methacholine inhalation with a greater than 20 per cent fall in the MMF and/or MTF. This response was significantly different from that of the control subjects (p less than 0.01). The patients' hyperresponsiveness appears to be similar to that of asthmatic patients except that the obstruction is primarily limited to the airways.
Coccidioides immitis occurring as a fungus ball within a chronic pulmonary cavity has previously been reported twice and must be rare. We report a mycetoma composed of both spherule and mycelial forms of Coccidioides immitis, proved by culture and histologic sections. Fungus ball due to Coccidioides immitis is a logical progression from mycelia seen in the cavity wall in the active pulmonary coccidioidal lung cavity.
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Little is known of the effect of chronic hemodialysis on lung function. In six patients with chronic uremia, we performed pulmonary function tests, sampled arterial blood, and measured the ventilatory response to carbon dioxide inhalation before and after routine hemodialysis. Patients were in the seated position throughout the study period. Routine pulmonary function was normal in all but one patient; a restrictive ventilatory defect was seen in a patient with prior pleuropericarditis and this was independent of fluid status. All patients showed improvement after dialysis in maximum flow rate at 25 per cent vital capacity corrected for changes in vital capacity (V max 25% VC/VC) supporting reversible obstruction of small airways. Hypoxemia was not precipitated by dialysis and all patients showed a small improvement in alveolar-arterial oxygen gradient. Although resting hyperventilation was documented in these patients, the ventilatory response to carbon dioxide inhalation was not consistently enhanced before or after hemodialysis.