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Biomedical subjects

S A Quadrelli

Publications and source records attributed to S A Quadrelli.

17 recordsLinked to original sources
PubMed1999

Evaluation of bronchodilator response in patients with airway obstruction.

The aim of this study was to define the most useful index of expressing bronchodilator response and to distinguish between asthma and COPD. A prospective study was carried out of bronchodilator response in 142 asthmatics and 58 COPD patients in a university hospital. Reversibility was expressed as: 1. absolute change (delta abs); 2. % of initial (delta %init); 3. % of predicted (delta %pred) and 4. % of maximum possible response (delta %max). Dependence on forced expirations volume in 1 sec (FEV1) as % of predicted and sensitivity and specificity for diagnosis of asthma were established. A relationship between delta abs and initial FEV1 was not found in asthma (delta abs vs. % initial FEV1. r = 0.07) or COPD (r = 0.02). delta %pred did not show a correlation in asthma (r = 0.10) or COPD (r = 0.06). delta %init was dependent on the baseline value in asthma (r = 0.38, P < or = 0.001) but not in COPD (r = 0.18, P = n.s.). delta max was dependent in both. The combination of best sensitivity and specificity to separate asthma and COPD was obtained with delta abs (70.4 or 70.6%). The worst specificity for asthma diagnosis was obtained with delta %init (50%). The best likelihood ratios were obtained with delta abs and delta %pred and the worst likelihood ratio with delta %init. delta %init is not recommended as an index for differential diagnosis between asthma and COPD; 2) delta %init overscores bronchodilator response in patients with low FEV1. The independence of each bronchodilator response index should be verified in clinical trials for each selected sample.

Aged↗
PubMed1999

[Beta-agonists: new perspective in the treatment of asthma?].

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Acute Disease↗
PubMed1998

Is asthma in the elderly really different?

To examine the nature of asthma in the elderly, we compared older (group 1: 65 years or older, n = 50) with younger patients (group 2: <40 years, n = 99) and to determine the influence of long-standing disease, elderly asthmatics with early onset (group A: onset before 40, n = 22) were compared with patients developing symptoms later in their lives (group B: onset after 40, n = 22). Blood eosinophilia and IgE value >/=100 IU/l were more frequent in younger patients. Short symptom-free periods were more frequent among older asthmatics (78.5 vs. 45.4%, p < 0.001). Only 31.2% of older patients had only mild symptoms. Requirement of systemic steroids was higher in the elderly population. The worst FEV1 was lower in older patients (54.4 +/- 17.3 vs. 71.8 +/- 18.5%, p </= 0.001). Patients with early-onset asthma showed more frequently shorter symptom-free periods (93.3 vs. 53.3%, p <0.05), higher emergency admissions/year, and hospitalizations/year. Best FEV1 (group 1: 66.7 +/- 13.7% vs. group 2: 90.3 +/- 15.1%, p < 0.005) and worst FEV1 (46.2 +/- 13.1 vs. 61.0 +/- 13.2%, p < 0.01) were lower in early-onset patients. A higher systemic steroid requirement, a lower best and worst FEV1, shorter symptom-free periods and a lesser proportion of patients with only mild symptoms were observed in patients older than 65 with early-onset asthma compared with those younger than 40 years. Elderly patients with a shorter duration of asthma were not different from young patients. Our study strongly suggests that severity of asthma and development of irreversible airflow obstruction depend on the duration of disease.

Adult↗
PubMed1998

[Non-invasive mechanical ventilation as treatment for severe pneumonia in an HIV positive patient].

A 27 year-old HIV+ patient was admitted to the hospital for probable Pneumocystis carinii pneumonia (PCP). He was severely dyspneic, with respiratory rate of 44 x min and accessory respiratory muscle contraction. The alveolar-arterial quotient was 0.35. Ventilation by BiPAP was applied during 12 hours. After BiPAP a/AO2 was O.42, with amelioration of dyspnea, decrease of respiratory rate (25 x min) and without using of accessory respiratory muscles. No complications occurred. At the end of hospital stay a/AO2 was 0.68. CPAP application but not BiPAP has been reported in PCP. Our patient showed evident improvement after BiPAP, suggesting that this method of ventilation is useful and should be incorporated to the routine management of these patients.

AIDS-Related Opportunistic Infections↗
PubMed1997

[Immediate postoperative respiratory complications after coronary surgery].

The influence of anesthesia, surgical procedure and special conditions of open-heart surgery upon respiratory function alterations is analyzed. Hypoxemia (present even in non-complicated open heart surgery) can be due to alveolar hypoventilation, ventilation-perfusion mismatch or shunt. The origin of atelectasias (present in 50-92% of patients) and pleural effusion (42-87%) is discussed. Phrenic nerve damage is usually secondary to thermal injury. Other less common complications are discussed. The influence of age, smoking and previous pulmonary diseases on respiratory complications is analyzed. Respiratory care after heart surgery (as time and requisites of extubations) and results of different methods (CPAP, PEEP, incentive inspirometry) are reviewed.

Coronary Disease↗
PubMed1996

Analysis of variability in interpretation of spirometric tests.

The objective of this study was to quantify the degree of disagreement in interpretation of spirometries and in the definition of the airway obstruction and response to bronchodilators (Bd) in different publications. Two surveys were carried out in which two groups of 15 pulmonologists were asked to identify in several spirometries the presence and degree of obstructive or restrictive defects (OD or RD), the response to Bd and whether the test was assessable or not. Three "problem' spirograms (PS) were included. For RD there was 76.1% of maximum agreement (MA). For OD the MA was 63.6%. Of the PS only 14% of the tests with a higher than 40% variation among the curves, 14% of those which did not include the graphic records and 33% of those with a considerably imperfect curve were considered nonassessable. The degree of disagreement for response to Bd was 24% (this implies 53.3% of possible maximal disagreement). Besides, every original article whose title or summary referred to "asthma', "chronic obstructive lung disease' or "chronic airflow obstruction' which was published from July 1991 to July 1993 in two respiratory medical journals (Chest and Thorax) was examined. Eleven different criteria to define obstruction were found. The most frequently used was FEV1/FVC < 70% (33.3%). Five different definitions of a positive response to Bd were found. The most popular was an increase in FEV1 > 15% of the initial value (76%). We conclude that there is very often disagreement in the interpretation of conventional spirometry. The definition of obstruction and reversibility in clinical trials is not uniform and great care must be taken when extrapolating the results from one publication to another since the composition of its samples could be substantially different.

Airway Obstruction↗
PubMed1996

Bilateral diaphragmatic paralysis after mediastinal radiotherapy.

A 35-year-old man presented bilateral phrenic paralysis 7 months after radio-therapy for treatment of Hodgkin's lymphoma. Diaphragmatic dysfunction appeared after complete lymphoma remission and 4 months after chemotherapy discontinuation. There were no other potential causes. Idiopathic diaphragmatic paralysis was unlikely because it is usually unilateral. Radiation-induced neuropathy is well documented in other nerves as the brachial plexus. The timing, the applied dose and the location of the nerve within the radiation field are suggestive of radiation-induced phrenic nerve damage. Partial recovery was achieved after 4 years' follow-up.

Adult↗
PubMed1995

[Gas exchange changes in the postoperative period of heart surgery].

We studied prospectively 59 open-heart surgical patients (CBPS) in order to evaluate postoperative arterial blood gases evolution and its predictive value of respiratory and non-respiratory post-surgical complications. Twenty-four hours after CPBS 28 over 59 patients showed left pleural effusion and/or left lower lobe atelectasis. 62.9% or pleural effusions were only blunted costophrenic angle. Chest x-ray film were normal in 38.9% (23/59) of patients. Forty-eight hours after CPBS only 5% (3/59) radiographs were normal and only 31% of pleural effusion were classified as minimal. Forty-eight hour radiographs worsened in 69.4% of the patients. (Table 1). During 48 hours period 71% of patients showed pleural effusion and 42% atelectasis. Only 1 patient showed an atelectasis up a third of hemithorax (3.5% of abnormal chest X-ray films). Twelve hours alveolo-arterial quotient (a/A) was decreased in 50/59 patients (0.51 +/- 0.16), more deeply at the second day. There was no relationship between CBP time and a/A at 12 or 48 hours. The normal chest X-ray film patients mean a/A was no different (0.54 +/- 0.17). The a/A at 48 hours was no different between patients with and without lower lobe atelectasis. Nine patients (15%) developed respiratory complications (RC) and 11 (19%) non-respiratory complications (NRC) (Table 2). There was no difference in CBP time (76.9 +/- 27.9 vs 88.1 +/- 27.7 min p = NS) nor aortic cross-clamp time (52.61 +/- 20.43 vs 59.57 +/- 19.39 min p = NS) between patients with and without RC. There were no differences in a/A at 12 hours (0.47, 0.51, 0.48 p = NS) and 48 hours (0.34, 0.32, 0.30 p = NS) between patients without complications, with RC and with NRC (Table 3). There was no correlation between 12 or 48 hours a/A and intensive care or hospital stay length. The absence of predictive value of hypoxemia could be explained from a different source of early a/A fall and important RC. It could mean that RC after CPBS are not specific of that sort of surgery nor involve mechanisms related to that special intraoperative circumstances, which is not the same for gas exchange alterations. We conclude that a/A deterioration is a very common finding after CBP and does not identify particularly risky patients.

Adult↗
PubMed1994

[Functional obstruction of the upper airway].

Laryngeal wheezing caused by emotional stress is usually confused with that caused by bronchospasm and diagnosed as asthma, a well known emotionally influenced entity. Therefore, it is treated with bronchodilators, including corticosteroids, frequently resulting in a iatrogenic Cushing's syndrome. This case report concerns a patient initially considered to have bronchial asthma. Physiological and endoscopic studies allowed us to exclude this disease, as well as any organic obstruction of the upper and lower airway. Flow-volume curve showed that the tidal volume (VT) loop was displaced towards RV during the crisis and the expiratory flow of the VT reached the envelope of the maximal expiratory flow (Fig. 1). Direct larynx observation during fiberoptic bronchoscopy showed not only expiratory but also inspiratory vocal cords adduction. A diagnosis of emotional laryngeal wheezing was made. Excluding asthma, bronchodilators were progressively discontinued. She started to receive alprazolam and psychotherapy and during one year of follow-up she remained symptomless. Two mechanisms may be present in our patient: partial inspiratory adduction of vocal cords and breathing at low lung volume. Despite reported dissimilarities between these two mechanisms both seem to have a similar emotional origin.

Airway Obstruction↗
PubMed1994

[Central alveolar hypoventilation with cor pulmonale: successful treatment by non-invasive intermittent positive pressure ventilation].

A 62 year-old woman with a bilateral carotid body paraganglioma presented, 2 years after the removal of the right one, with signs of right-heart failure. Hypoxemia, hypercapnia, polycythemia and pulmonary hypertension with normal ventilatory capacity were found. Central alveolar hypoventilation was diagnosed on the basis of absence of ventilatory response and sensation of provoked hypercapnia, prolonged breath-holding time and correction of hypercapnia by voluntary ventilation. Progesterone (200 mg/d during 3 weeks) or naloxone did not improve either arterial blood gases (ABG) or the P 0.1/PCO2 curve. Hypoxemia and hypercapnia were not corrected during metabolic acidosis provoked by acetazolamide (250 mg/d). Nasal CPAP did not control hypoventilation periods. Mechanical ventilation was initiated with negative pressure (NPV) through a poncho. The patient presented severe discomfort with NPV and obstructive apneas were verified during it. She refused to continue NPV. Mechanical ventilation was initiated with positive intermittent pressure (IPPV) through a nasal mask. The patient had excellent tolerance to the procedure. SpO2 during IPPV was always higher than 95%. During sleep induction (under IPPV), respiration in phase with the ventilator 1: 1 was observed; instead, during consolidated sleep there was a complete dependence of the ventilator with apnea for over 2 min when IPPV was interrupted (Fig. 1). After 2 months of treatment, a relief of right ventricular failure occurred and hematocrit fell to 39%. There was an improvement of day-time ABG (Table I). The P. 0.1/PaCO2 curve 3 months after IPPV was the same as the previous one (Fig. 2). The patient has been for 18 months on home ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Female↗
PubMed1994

[Treatment of respiratory insufficiency secondary to vocal cord bilateral paralysis with continuous positive pressure].

Vocal cord paralysis can produce extrathoracic airway obstruction with severe respiratory failure, post-surgical traumatism being the most frequent. Definitive treatment can require aritenoidectomy. For emergency treatment tracheal intubation of tracheotomy are frequently needed. We report a patient with acute post-surgical upper airway obstruction successfully treated with CPAP application through nasal mask. A 29 year-old female showed stridor and retraction of the supraclavicular, intercostal and epigastric region following an uncomplicated tracheal extubation immediately after surgery (radical thyroidectomy with nodal dissection). Pulsosaturometry showed O2 desaturation despite high flow O2 administration. She received intravenous steroids and O2 through intermittent positive pressure by nasal mask (manual resuscitator) increasing SpO2 to 90%. Laringoscopy showed both vocal cords fixed at medium line. CPAP through a nasal mask was initiated with a 5 cm H2O pressure and high FIO2. Immediately afterwards, dyspnea, stridor, supraclavicular retraction and respiratory accessory muscles use disappeared. Heart rate decreased (120 to 92 x min.) and SpO2 increased to 99%. Arterial blood gases did not show hypercapnia. Dyspnea and physical signs of upper airway obstruction appeared immediately after interrupting CPAP application, with a marked decrease in SpO2. So the mask was reinstalled keeping the same pressure level during 18 hs. The procedure was well tolerated. There were no local or hemodynamic complications. CPAP was progressively discontinued.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

[Error factors in spirometry].

Spirometry is the more frequently used method to estimate pulmonary function in the clinical laboratory. It is important to comply with technical requisites to approximate the real values sought as well as adequate interpretation of results. Recommendations are made to establish: 1--quality control 2--define abnormality 3--classify the change from normal and its degree 4--define reversibility. In relation to quality control several criteria are pointed out such as end of the test, back-extrapolation and extrapolated volume in order to delineate most common errors. Daily calibration is advised. Inspection of graphical records of the test is mandatory. The limitations to the common use of 80% of predicted values to establish abnormality is stressed. The reasons for employing 95% confidence limits are detailed. It is important to select the reference values equation (in view of the differences in predicted values). It is advisable to validate the selection with local population normal values. In relation to the definition of the defect as restrictive or obstructive, the limitations of vital capacity (VC) to establish restriction, when obstruction is also present, are defined. Also the limitations of maximal mid-expiratory flow 25-75 (FMF 25-75) as an isolated marker of obstruction. Finally the qualities of forced expiratory volume in 1 sec (VEF1) and the difficulties with other indicators (CVF, FMF 25-75, VEF1/CVF) to estimate reversibility after bronchodilators are evaluated. The value of different methods used to define reversibility (% of change in initial value, absolute change or % of predicted), is commented. Clinical spirometric studies in order to be valuable should be performed with the same technical rigour as any other more complex studies.

Adolescent↗