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PubMed2005

Functional status and patient satisfaction: a comparison of ischemic heart disease, obstructive lung disease, and diabetes mellitus.

OBJECTIVE: To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics. DESIGN: Cross-sectional mailed questionnaire study. SETTING: Primary care clinics at 7 Veterans Affairs medical centers. PATIENTS/PARTICIPANTS: Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample. MEASUREMENTS AND MAIN RESULTS: The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized beta=0.18; P<.001) but self-reported physical limitation due to angina was not (beta=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (beta=0.11; P<.001) but physical function was not (beta=-0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (beta=0.31; P<.001) but improvement in symptom burden was not (beta=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores. CONCLUSIONS: Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.

Adaptation, Psychological↗
PubMed2006

Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study.

OBJECTIVE: To determine whether a modified Global Initiative on Obstructive Lung Diseases (GOLD) classification of chronic obstructive pulmonary disease (COPD) predicts mortality in a cohort of subjects followed for up to 11 years. METHODS: We analyzed data from 15,759 adult participants, aged 43-66 years at baseline, in the Atherosclerosis Risk in Communities (ARIC) study. All baseline and follow-up data were available for 15,440 (97.9%) of the initial participants. We classified subjects using a modification of the GOLD criteria for COPD (prebronchodilator forced expiratory volume in 1s (FEV(1)) stratification of disease severity), and added a "restricted" category (FEV(1)/FVC>70% and FVC<80% predicted). We used Cox proportional hazard models to determine the risk of impaired lung function on subsequent mortality, after adjusting for age, race, sex and smoking status. RESULTS: 1242 (8.0%) subjects died by the end of 1997. The overall rate of death was 8.9 per 1000 person years, but varied from 5.4/1000 among normal subjects to 42.9/1000 among subjects with GOLD Stage 3 or 4 COPD. After adjusting for covariates, all GOLD categories, along with the restricted category, predicted a higher risk of death: GOLD Stage 3 or 4, hazard ratio (HR) 5.7, 95% confidence interval (CI) 4.4, 7.3; GOLD Stage 2 HR 2.4, 95% CI 2.0, 2.9; GOLD Stage 1 HR 1.4, 95% CI 1.1, 1.6; GOLD Stage 0 HR 1.5, 95% CI 1.3, 1.8; and restricted HR 2.3, 95% CI 1.9, 2.8. CONCLUSION: The modified GOLD classification system of COPD predicts mortality in this cohort of middle-aged Americans followed for up to 11 years.

Adult↗
PubMed2003

Superoxide dismutases in the lung and human lung diseases.

The lungs are directly exposed to higher oxygen concentrations than most other tissues. Increased oxidative stress is a significant part of the pathogenesis of obstructive lung diseases such as asthma and chronic obstructive pulmonary disease, parenchymal lung diseases (e.g., idiopathic pulmonary fibrosis and lung granulomatous diseases), and lung malignancies. Lung tissue is protected against these oxidants by a variety of antioxidant mechanisms among which the superoxide dismutases (SODs) are the only ones converting superoxide radicals to hydrogen peroxide. There are three SODs: cytosolic copper-zinc, mitochondrial manganese, and extracellular SODs. These enzymes have specific distributions and functions. Their importance in protecting lung tissue has been confirmed in transgenic and knockout animal studies. Relatively few studies have been conducted on these enzymes in the normal human lung or in human lung diseases. Most human studies suggest that there is induction of manganese SOD and, possibly, extracellular SOD during inflammatory, but not fibrotic, phases of parenchymal lung diseases and that both copper-zinc SOD and manganese SOD may be downregulated in asthmatic airways. Many previous antioxidant therapies have been disappointing, but newly characterized SOD mimetics are being shown to protect against oxidant-related lung disorders in animal models.

Animals↗
PubMed2000

Moderately early (7-14 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants.

BACKGROUND: Corticosteroids have been used late in the neonatal period to treat chronic lung disease (CLD) in preterm babies and early to try to prevent it. CLD is likely to be the result of persisting inflammation in the lung and the use of powerful anti-inflammatory drugs like dexamethasone has some rationale. Early use tends to be associated with increased adverse effects so that studies of moderately early treatment (7-14 days postnatal) might have the dual benefits of fewer side effects and onset of action before chronic inflammation is established. OBJECTIVES: To determine if moderately early (7-14 days) postnatal corticosteroid treatment vs control (placebo or nothing) is of benefit in the prevention and/or treatment of early chronic lung disease in the preterm infant. SEARCH STRATEGY: Randomised controlled trials of postnatal corticosteroid therapy were sought from the Oxford Database of Perinatal Trials, Cochrane Database of Controlled Trials, Medline, hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists. SELECTION CRITERIA: Randomised controlled trials of postnatal corticosteroid treatment from 7-14 days of birth in high risk preterm infants were selected for this review. DATA COLLECTION AND ANALYSIS: Data regarding clinical outcomes including mortality up to 28 days and before discharge, failure to extubate, mortality and / or chronic lung disease at 28 days and 36 weeks, CLD at 28 days and 36 weeks, infection, hyperglycaemia, hypertension, severe retinopathy of prematurity (ROP), pneumothorax, necrotizing enterocolitis (NEC), gastrointestinal bleeding, severe intraventricular hemorrhage (IVH), hypertrophic cardiomyopathy, late rescue with dexamethasone and abnormal neurological examination at follow-up were abstracted and analysed using Revman 4.0.4. MAIN RESULTS: Moderately early steroid treatment (vs placebo or nothing) reduced mortality by 28 days, chronic lung disease at 28 days and 36 weeks, and death or chronic lung disease at 28 days or 36 weeks. Earlier extubation was facilitated. There was no significant effect on the rates of pneumothorax, severe ROP, and NEC. Adverse effects included hypertension, hyperglycaemia, gastrointestinal bleeding, hypertrophic cardiomyopathy and infection. Steroid-treated infants were less likely to need late rescue with dexamethasone. There was only one small study of longterm follow-up and it did not show any increase in adverse neurological outcome. REVIEWER'S CONCLUSIONS: Moderately early corticosteroid therapy (started at 7-14 days) reduces neonatal mortality and CLD, but at the cost of important short term adverse effects. No reliable evidence concerning long term effects is provided by the trials included in this review. In view of the evidence of an important increase in cerebral palsy and other adverse neurodevelopmental outcomes from trials in which postnatal steroid was begun either earlier or later than 7-14 days, there are reasonable grounds for extending this concern to moderately early initiation of steroid therapy. More research is urgently needed, including long term follow-up of survivors included in previous and any future trials, before the benefits and risks of postnatal steroid treatment, including initiation at 7-14 days, can be reliably assessed.

Anti-Inflammatory Agents↗
PubMed2000

Aerosolized diuretics for preterm infants with (or developing) chronic lung disease.

BACKGROUND: Lung disease in preterm infants is often complicated with lung edema. OBJECTIVES: The aim of this review is to assess the risks and benefits of aerosolized diuretic administration in preterm infants with or developing chronic lung disease (CLD). Primary objectives are to assess effects on short term outcome (changes in need for oxygen or ventilatory support) and effects on long-term outcome. Secondary objectives are to assess changes in pulmonary mechanics and potential complications of therapy. SEARCH STRATEGY: We used the standard search method of the Cochrane Neonatal Review Group. We used the following keywords: ¿ or ¿ and , limited to and limited to or . We searched Medline (1966-1998), Embase (1974-1998) and the Cochrane Controlled Trials Register (CCTR) from the Cochrane Library (1998, Issue 4). In addition, we hand searched several abstract books of national and international American and European Societies. SELECTION CRITERIA: We included in this analysis trials in which preterm infants with or developing chronic lung disease and at least five days of age were all randomly allocated to receive an aerosolized loop diuretic. Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included important clinical outcomes, and secondary outcome variables included pulmonary mechanics and potential complications of therapy. DATA COLLECTION AND ANALYSIS: We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS: We identified eight studies which met selection criteria. Most studies focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review or the potential complications of diuretic therapy. No study assessed the amount of diuretic effectively delivered to the patient. Furosemide was the only diuretic used in the eight studies included in this review. Among preterm infants < 3 weeks of age developing CLD, not enough information is available to assess the effect of aerosolized furosemide on outcome or lung function. Among infants > 3 weeks with CLD, a single aerosolized dose of 1 mg/kg of furosemide may transiently improve pulmonary mechanics. Not enough information is available to assess the effect of chronic administration of aerosolized furosemide on oxygenation and pulmonary mechanics. REVIEWER'S CONCLUSIONS: In preterm infants > 3 weeks with CLD administration of a single dose of aerosolized furosemide improves pulmonary mechanics. In view of the lack of data from randomized trials concerning effects on important clinical outcomes, routine or sustained use of aerosolized loop diuretics in infants with (or developing) CLD cannot be recommended based on current evidence. More double-blinded randomized trials are needed (1) to analyze factors likely to affect the response to aerosolized furosemide, e.g. , washout period and delivery of furosemide to distal airways, and (2) to assess the effects of chronic administration of aerosolized furosemide on mortality, O2 dependency, ventilator dependency, length of hospital stay and long-term outcome.

Aerosols↗
PubMed2005

Prognostic risk factors in patients with interstitial lung disease referred for lung transplantation.

The aim of the study was to identify prognostic factors that would differentiate patients with interstitial lung disease between those with and without a chance to survive until lung transplantation. A retrospective study was performed in patients with interstitial lung disease referred for lung transplantation between September 1999 and April 2005. The analysis included the demographic data, the time from referral to transplantation, the functional tests (FVC, FEV1, FEV1%VC, the PaO(2) at rest and after oxygen supplementation via a nasal catheter), the count of NYHA functional classes, the left ventricular ejection fraction (EF), the distance covered during a 6-min walk test, and the pathogens in the respiratory tract. The patients were divided into two groups: Group 1 - lung transplant candidates who survived until the successful procedure and Group 2 - lung transplant candidates who died while on the waiting list. There were statistical differences between the two groups in PaO2 after supplementation (P=0.005), EF (P=0.002), and the 6-min walk distance (P=0.001). It appears that simple functional tests of the cardiorespiratory system may define survival of patients with interstitial lung disease waiting for lung transplantation.

Adult↗
PubMedDate not supplied

Value of spirometry in detecting volume restriction in interstitial lung disease patients. Spirometry in interstitial lung diseases.

BACKGROUND: Restriction is a typical functional abnormality in interstitial lung disease (ILD) patients, but is not always present, especially in the early stage of the disease. The greater reduction of vital capacity (VC; %pred.) than total lung capacity (TLC; %pred.) is regarded as a typical pattern of lung function disturbances in ILD patients. STUDY OBJECTIVES: To explore the diagnostic value of spirometry in a detection restrictive pattern the relative volume loss assessed by TLC and VC in large series of patients with a diagnosis of ILD referred for lung function tests was evaluated. METHODS: Retrospective, cross-sectional analysis of pulmonary function data was done. The sampleconsisted of 1,173 patients with the diagnosis of different interstitial lung diseases investigated during a period of 5 years. Only patients without airway obstruction (normal FEV1%VC) were included. In all cases spirometry and whole body plethysmography were performed by experienced staff using MasterLab - 'Jaeger' equipment according to ERS standards. Reference values according to ERS guidelines were applied. RESULTS: The mean value of TLC expressed as %pred. was significantly (p < 0.001) lower than VC in all patients (93.7 +/- 18.6 vs. 98.0 +/- 21.4%pred.). The frequency of abnormal (lowered) TLC results was also higher than lowered VC (22.8 vs. 17.8%). Sensitivity of VC reached 69.3% and the positive predictive value was 88.5% in detecting volume restriction as compared to TLC measurement. CONCLUSION: The relative loss of TLC was greater than VC in our large group of patients. Measurement of TLC should be part of functional assessment of ILD patients, irrespective of whether they present or do not present a restrictive pattern in spirometry.

Adolescent↗
PubMed2000

Accuracy of echocardiographic right ventricular parameters in patients with different end-stage lung diseases prior to lung transplantation.

BACKGROUND: Because there are few data available on the accuracy of 2D-echocardiography to assess right ventricular (RV) size and function in patients with far-advanced lung disease, in this prospective study, we compared various echocardiographic RV parameters with RV volumes derived from magnetic resonance imaging (MRI). METHODS: In 32 patients (18 male, 17 female) presenting for lung transplantation, we measured RV end-diastolic and end-systolic area as well as derived RV fractional area change, long-axis diameter, short-axis diameter, tricuspid valve anulus diameter (using 2D apical or sub-costal 4-chamber view), and RV end-diastolic diameter (using M-mode in the parasternal short-axis view). These values were compared with RV end-diastolic and end-systolic volumes derived by MRI, serving as the gold standard. RESULTS: Right ventricular end-diastolic area was the most accurate echocardiographic parameter of RV size (correlation to MRI: r = 0.88, p < 0.001), followed by RV end-diastolic short-axis diameter (r = 0.75, p < 0.001), long axis diameter (r = 0.66, p < 0.001), and tricuspid valve anulus diameter (r = 0.63, p < 0.001). In contrast, M-mode measurement of RV end-diastolic diameter was possible in only 24/35 (68%) patients and showed a weak correlation to MRI-derived RV end-diastolic volume (r = 0.56, p = 0.004). Right ventricular fractional area change correlated well with MRI-derived RV ejection fraction (r = 0.84, p < 0.0001). In a sub-group analysis, patients with vascular lung disease showed best agreement between both methods for RV end-diastolic area and RV fractional area change compared with patients with restrictive or obstructive lung disease. CONCLUSION: This study shows that in patients with far-advanced lung diseases, RV end-diastolic area demonstrated the best correlation with MRI-derived measurement of RV end-diastolic volume, and RV fractional area change compared favorably with MRI-derived ejection fraction. Despite reduced image quality, especially in patients with obstructive lung disease, these parameters can yield clinically valuable information.

Adult↗
PubMed2005

Does interstitial lung disease predispose to lung cancer?

PURPOSE OF REVIEW: This review examines the evidence for the causality and pathogenesis of lung cancer associated with interstitial lung disease. RECENT FINDINGS: Although cigarette smoking is the leading cause of lung cancer, several other conditions either predispose to lung cancer or increase the risk of lung cancer in smokers. The evidence supports an increased risk of lung cancer due to specific fibrotic and inflammatory lung diseases (termed interstitial lung diseases), including idiopathic pulmonary fibrosis, systemic sclerosis, and certain pneumoconioses. The potential pathogenetic mechanisms indicate that recurrent injury and inflammation result in genetic alterations that predispose to lung cancer. SUMMARY: Idiopathic pulmonary fibrosis, systemic sclerosis, and certain pneumoconioses are associated with an independent increased risk of lung cancer; however, a unifying pathogenetic mechanism to explain the causality of this association has not been described. In addition, the inconsistently reported lung cancer frequencies call attention to the need for prospective studies of good quality.

Causality↗
PubMed1992

The effects of inhaled albuterol and oral theophylline on gastroesophageal reflux in patients with gastroesophageal reflux disease and obstructive lung disease.

Patients with gastroesophageal reflux disease may have pulmonary symptoms due to repeated aspiration of gastric contents or reflex bronchospasm during a reflux event. Oral bronchodilators are known to worsen gastroesophageal reflux and may lead to vicious cycle when gastroesophageal reflux causes bronchospasm. The effect of inhaled bronchodilators on gastroesophageal reflux is unknown. We compared the severity of gastroesophageal reflux in patients with documented gastroesophageal reflux disease and obstructive lung disease while they were taking inhaled albuterol or oral theophylline. Nine patients with gastroesophageal reflux disease had 24-hour esophageal pH studies on two separate days approximately 1 week apart. On one study day, the patients received 0.5 mg of albuterol in 2.5 mL of normal saline vias hand-held nebulizer, four times a day. On the other day, the patients received sustained-release theophylline, 200 mg twice a day, or in a dosage taken previously to achieve a serum theophylline level of 55 to 110 mumol/L. The patients had 40% reduction in the total time the pH was less than 4.0 with albuterol than with theophylline (9.7% vs 16.1%). Seven patients had less gastroesophageal reflux while taking albuterol, and two patients had essentially no change. Patients with gastroesophageal reflux disease, who require bronchodilator therapy for obstructive lung disease, have less reflux with inhaled albuterol.

Administration, Inhalation↗
PubMed1991

Comparison of outcomes of double and single lung transplantation for obstructive lung disease. The Toronto Lung Transplant Group.

Single lung transplantation has recently been applied with success in patients with obstructive lung disease. Such patients were previously managed by bilateral pulmonary transplantation. Between November 1986 and January 1990, 18 patients underwent transplantation for obstructive lung disease in our center. Eleven double lung transplants and seven single lung transplants were performed in patients having a mean age of 43.4 and 44.1 years, respectively. Operative death occurred in two of 11 double lung transplantations and one of seven single lung transplantations. Each patient underwent preoperative and 3-month postoperative pulmonary function tests, arterial blood gas analyses, nuclear lung scans, and 6-minute walk tests. There was no difference in the preoperative values for any of these parameters. Double lung recipients had significantly higher forced expiratory volume in 1 second and forced vital capacity than single lung recipients. However, the ratios of forced expiratory volume in 1 second to vital capacity were not different. Arterial oxygen and carbon dioxide tension were not different between the two procedures. Whereas double lung transplantations caused a slight preponderance of perfusion to the right lung, the transplanted lung in single lung recipients received a mean of 79.5% +/- 12.3% of predicted flow and only 61.6% +/- 5.0% of predicted ventilation. Three-month 6-minute walk distances were markedly improved in both groups, with double lung recipients achieving 573.0 +/- 44.7 m in comparison with the 528.0 +/- 43.0 m achieved by the single lung recipients. Single lung transplantation is a satisfactory option in patients with obstructive lung disease and might offer significant advantages to the older patient population, in which risk of double lung transplantation is high.

Adult↗
PubMed1995

[Interstitial lung disease in patients with connective tissue diseases].

Interstitial lung disease is a significant prognostic factor in connective tissue diseases. To further clarify clinical and immunological features of interstitial lung disease, we studied 894 consecutive patients with connective tissue diseases first evaluated between 1970 and 1993. Interstitial lung disease was found in 101 of 181 (56%) patients with systemic sclerosis, 92 of 183 (50%) with overlap syndrome, 35 of 76 (46%) with polymyositis/dermatomyositis, and 13 of 444 (3%) with systemic lupus erythematosus (p < 0.05, systemic lupus erythematosus vs. other connective tissue diseases). The presence of interstitial lung disease correlated with decreased survival in systemic sclerosis and in polymyositis/dermatomyositis, but not in overlap syndrome or in systemic lupus erythematosus. Interstitial lung disease in patients with connective tissue diseases was classified into two types: acute (n = 8) and chronic (n = 233). Among the 8 patients with acute disease, 4 (all with dermatomyositis) died of respiratory failure and 3 (all with systemic lupus erythematosus) responded to corticosteroids. Among the 233 patients with chronic interstitial lung disease, 20 had polymyositis/dermatomyositis with anti-aminoacyl tRNA synthetase antibodies and 40 had overlap syndrome with anti-U1 RNP antibodies. Respiratory failure in these patients was not frequent and occurred late in the course of the disease. As a cause of death, respiratory failure was associated with autoantibodies to topoisomerase I and aminoacyl tRNA synthetase but not anti-U1 RNP. Autoantibodies to aminoacyl tRNA synthetases were detected before the development of interstitial lung disease in 9 patients with polymyositis/dermatomyositis. We conclude that the clinical features of interstitial lung disease associated with connective tissue diseases vary with the type of connective tissue disease, and that analysis of autoantibodies can be useful in establishing a diagnosis and in forecasting the course and outcome.

Adult↗
PubMed2003

[Sjören's syndrome with infiltrative lung disease showing upper lung field predominance].

We report two cases of Sjören's syndrome (SjS) with infiltrative lung disease showing upper lung field predominance. Case 1 was seen in a 68-year-old woman, who was admitted with dyspnea on exercise. Chest CT scanning demonstrated a central predominance of irregularly shaped consolidation with tractionectasis, distributed along the broncho-vascular bundles in both upper lobes. Case 2 occurred in a 70-year-old woman, who was admitted with cough. Chest CT scan showed a central predominance of irregularly shaped opacities with multiple small cystic structures in both upper lobes. Both cases were shown to be nonspecific interstitial pneumonia (NSIP) by video-assisted thoracoscopic lung biopsy, in which lung involvements were distributed around the bronchovascular sheath with relative sparing of the subpleural region. Although neither case complained of sicca symptoms, decreased saliva production was detected using the Saxon test, and further examinations revealed the presence of primary SjS. Pulmonary involvement in SjS is variable, and distribution along the broncho-bronchioles in the majority of the upper central lung field is a characteristic appearance of SjS lung disease. In patients with such patterns in chest radiography, further diagnostic differentiation should be conducted to confirm or rule out SjS.

Aged↗
PubMed2000

Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease.

OBJECTIVES: The aim of this review is to assess the risks and benefits of diuretics acting on distal segments of the renal tubule (distal diuretics) in preterm infants with or developing chronic lung disease (CLD). Primary objectives are to assess changes in need for oxygen or ventilatory support and effects on long-term outcome, and secondary objectives are to assess changes in pulmonary mechanics and potential complications of therapy. SEARCH STRATEGY: We used the standard method of the Cochrane Neonatal Review Group. We used the following keywords: ¿ or ¿ and , limited to and limited to or . We searched Medline (1966-1998), Embase (1974-1998) and the Cochrane Controlled Trials Register (CCTR) from the Cochrane Library (1999, issue 2). In addition, we hand searched several abstract books of national and international American and European Societies. SELECTION CRITERIA: We included in this analysis trials in which preterm infants with or developing CLD and at least five days of age were all randomly allocated to receive a distal diuretic (i.e., a diuretic acting on the distal renal tubule). Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included changes in need for respiratory support and oxygen supplementation, mortality, bronchopulmonary dysplasia (BPD), death or BPD, chronic lung disease at 36 weeks of postconceptional age (gestational age + postnatal age), length of stay, and number of rehospitalizations during the first year of life. Secondary outcome variables included pulmonary mechanics and potential complications of therapy. DATA COLLECTION AND ANALYSIS: We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. MAIN RESULTS: Of six studies fulfilling entry criteria, most focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants > 3 weeks of age with CLD, a four-week treatment with thiazide and spironolactone improved lung compliance and reduced the need for furosemide. Thiazide and spironolactone decreased the risk of death and tended to decrease the risk for lack of extubation after 8 weeks in intubated infants. There is no evidence to support the hypothesis that adding spironolactone to thiazide or that adding metolazone to furosemide improves the outcome of preterm infants with CLD. REVIEWER'S CONCLUSIONS: In preterm infants > 3 weeks of age with CLD, acute and chronic administration of distal diuretics improve pulmonary mechanics. Chronic administration of diuretics (thiazide with spironolactone) reduces mortality in intubated patients. Large studies are needed to assess (1) whether chronic diuretic administration improves mortality, duration of oxygen dependency, ventilator dependency, length of hospital stay and long-term outcome in patients without long-term toxicity and (2) whether adding spironolactone to thiazides or adding metolazone to furosemide has any beneficial effect.

Chronic Disease↗