A study of 18 different commercially available continuous-flow, jet nebulizers was performed with a standard liposomal formulation of beclomethasone dipropionate (Bec-DP) prepared with dilauroyl phosphatidylcholine (Bec-DLPC). The analysis compared the total Bec-DP output from aqueous suspensions of Bec-DLPC containing an initial starting reservoir concentration of 0.5 mg/ml. Aerosols from each nebulizer tested were characterized by the mass median aerodynamic diameter, geometric standard deviation, drug output, and the predicted percentage regional deposition of inhaled Bec-DLPC liposomes within the human respiratory tract. These data can provide a basis for the selection of commercially available jet nebulizers for use with glucocorticoid liposome aerosols for treatment of asthma and other inflammatory lung diseases.

Invasive pulmonary aspergillosis (IPA), although unusual, has been recognized in the immunocompetent host. Several cases of IPA with rapidly progressive respiratory failure have been reported in patients receiving short-term corticosteroid therapy for chronic obstructive pulmonary disease. Atypical pneumonia caused by dual infection with Legionella pneumophila and Mycoplasma pneumoniae has also been reported. We report an unusual case of simultaneous L pneumophila pneumonia and IPA in an asthma patient with suspected allergic bronchopulmonary aspergillosis newly treated with corticosteroids.

Nasal continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) is usually titrated in a sleep laboratory with full polysomnographic monitoring until apneas, nonapneic desaturation, snoring, and microarousals are eliminated. This titration is sometimes done in the second half of the diagnostic sleep study or commonly on a separate second full night in the sleep laboratory. We performed NCPAP titration in the home in 17 patients with OSA previously documented by full polysomnography. Nasal CPAP was titrated at night in the patient's home by a registered nurse or polysomnography technician monitoring real-time recordings of heart rate, thoracic impedance, oxygen saturation, and pressure at the nasal mask on a four-channel recorder (EdenTec, Eden Prairie, Minn). Recordings of the nasal CPAP titration night were reviewed later by a physician. Apneas, hypopneas, and snoring were successfully eliminated in all patients. Mean nasal CPAP pressure was 10.3 +/- 3.2 cm H2O. At the time of a follow-up interview, 13 of 17 patients continued to be compliant with nasal CPAP therapy. The mean duration of therapy was 13.4 +/- 11.7 months with 7.23 mean hours of use for 6.76 nights per week. This compliance compares favorably with long-term home nasal CPAP compliance previously reported in patients titrated in our sleep laboratory. Home nasal CPAP titration resulted in about a $600 savings per patient.

Intravascular thrombosis is postulated to cause or to contribute to the development of uncharacterized ("primary") pulmonary hypertension (PPH). To assess whether there is ongoing platelet-fibrin thrombosis in patients with PPH, we measured specific markers of platelet activation: platelet factor 4 (PF4) and beta-thromboglobulin (BTG); of fibrin formation: fibrinopeptide A (FPA); and of fibrin dissolution: fibrinopeptide BB1-42 (FPBB1-42) in peripheral venous blood from 10 patients with PPH (group 2). Results were compared with those of normal volunteers (group 1, n = 9) and with results from patients with pulmonary hypertension secondary to congenital heart disease (group 3, n = 7). Both groups 2 and 3 exhibited severe pulmonary hypertension (mean pulmonary arterial pressure = 62 +/- 20 mm Hg and 70 +/- 13 mm Hg, respectively). Mean level of PF4, BTG, FPA, and FPBB1-42 in patients with pulmonary hypertension, either primary or secondary to congenital heart disease, did not differ from levels in normal subjects. Within group 2, levels of platelet proteins and fibrinopeptides did not differ between patients who were classified clinically as having plexogenic arteriopathy vs thromboembolic disease. These observations suggest that a sustained state of abnormal platelet activation and fibrin formation or dissolution is not present in patients with established pulmonary hypertension.

Clarithromycin is a new acid-stable, 14-membered macrolide active against many of the organisms responsible for lower respiratory tract infections. It has been administered to over 5,000 patients worldwide and has been shown to be a safe and effective treatment for acute bacterial exacerbations of chronic bronchitis and bacterial pneumonia when given twice daily (250 to 500 mg). Cefixime is an amino-thiazolyl cephalosporin with an extended spectrum of antibacterial activity inhibiting beta-lactamase-producing respiratory pathogens. It has a long half-life, allowing once-daily administration.

Clinicians and surgeons have used the subjective response to the climb of "one or two flights of stairs" to assess the "reserve" of patients with chronic airflow obstruction (CAO). Very little objective data exist regarding the metabolic and ventilatory cost for any level of stair climbing in these patients. Therefore, this study was designed to evaluate the use of symptom-limited stair climbing as a simple method to estimate the peak oxygen uptake (VO2) and minute ventilation (VE) in patients with CAO. We studied 31 men with varying degrees of CAO, who climbed stairs until they stopped at their symptom-limited maximum. During this climb, timed expired gas was intermittently collected and analyzed, and oxygen saturation and heart and respiratory rates were recorded. The patients achieved 81 +/- 14 percent of their predicted maximal heart rate and 90 +/- 27 percent of their predicted maximal VE. The number of steps or flights climbed correlated linearly with peak VO2 (r = 0.72, p < 0.01) and with VE (r = 0.7, p < 0.01). Stair climbing peak VE, VO2, heart and respiratory rate correlated well with those achieved during standard leg cycle ergometry. The mean +/- SD number of flights climbed was 4.2 +/- 1.7 with most patients (87%) reaching at least 3 flights (54 steps). The group of eight patients with very severe CAO (FEV1 < 0.9 L) climbed 3.4 +/- 0.9 flights (61 +/- 16 steps). We conclude that a symptom-limited maximal stair climb helps estimate peak VO2 and VE in patients with CAO. The frequently advocated test to climb one to two flights to evaluate cardiopulmonary reserve is not adequate for most patients with CAO. Symptom-limited maximal stair climbing is a simple, inexpensive and readily available test that may be used to evaluate the cardiopulmonary reserve of stable patients with CAO.

Chemical pleurodesis is a frequently performed procedure for pneumothorax and effusion and significant adverse effects are unusual. We present a previously unreported case of acute renal failure associated with tetracycline pleurodesis. Recent studies have shown that intrapleural drug administration may lead to therapeutic serum levels. Systemic toxic drug effects may therefore be noted with chemical pleurodesants such as tetracycline. Alternative methods of pleurodesis should always be considered if a sensitivity or metabolic abnormality is suspected.

A patient presented with an acute right ventricular infarction characterized by an electrocardiographic current of injury in both the inferior (2,3,aVF) and anterior precordial leads (V1-V6). Cardiac catheterization demonstrated normal left ventricular wall motion, a codominant circulation, and severe disease of the right coronary artery. We propose that this coronary anatomy explains the injury currents on the electrocardiogram. This case illustrates a rare presentation of right ventricular myocardial infarction mimicking an extensive anterolateral wall injury.

Subjects with isolated complaints of chronic daytime sleepiness are usually classified as "idiopathic hypersomniacs" and treated symptomatically. A group of these subjects was investigated during nocturnal sleep and daytime naps. In a subgroup of them, sleep was fragmented by very short alpha EEG arousals throughout the sleeping period. These short arousals are usually ignored in sleep analyses, but their impact is significant (in the 15 subjects identified with the syndrome, the mean sleep latency in multiple sleep latency tests was 5.1 +/- 1 min). These arousals are directly related to an abnormal increase in respiratory efforts during sleep (the mean peak inspiratory esophageal pressure measured in our subjects in the respiratory cycle just preceding a transient arousal was -33 +/- 7 cm H2O). Typically, an arousal occurs within one to three breaths of flow limitation associated with abrupt but limited reduction in tidal volume (ie, abnormal increase in upper airway resistance during sleep). The arousal restores normal breathing. Snoring was noted in association with these transient arousals in 10 of the 15 subjects; however, snoring was neither sufficient nor necessary for the identification of the clinical syndrome. Both sexes were equally represented in the affected group. All studied subjects had upper airway anatomy that was mildly abnormal. Nasal continuous positive airway pressure, used as an experimental tool, eliminated the daytime sleepiness (multiple sleep latency mean score = 13.5 min), the transient arousals (mean alpha EEG arousal index decreased from 31.3 +/- 12.4 to 8 +/- 2 per hour of sleep), and the abnormal upper airway resistance. Chronic daytime sleepiness is a major cause of social, economic, and medical impairment. Recognition of this syndrome and its cause is important, as specific treatments can be developed to eliminate the problem.

Two patients receiving positive pressure ventilation experienced marked gaseous abdominal distension. Analysis of gases from the stomach, ventilator, and room air suggested that the gastric gases came from the ventilator in one patient. The diagnosis of tracheoesophageal fistula was confirmed by esophagoscopy. Analysis of gases in the other patient did not support the suspicion of tracheoesophageal fistula, and no fistula was found at autopsy. The technique of gastric air analysis is presented as a simple supporting tool for the clinical diagnosis of tracheoesophageal fistula in patients receiving positive pressure ventilation.

Cardiac amyloidosis produces a restrictive cardiomyopathy with impaired diastolic function. We report a case in which low-dose verapamil resulted in marked worsening of congestive heart failure, as a result of a profound negative inotropic effect. Withdrawal of verapamil therapy demonstrated a return of systolic function to normal with improvement in heart failure. We postulate that patients with cardiac amyloidosis may be exceptionally sensitive to the negative inotropic effects of calcium-channel blockers either because of abnormal binding to amyloid fibrils or because their usual vasodilator effects are blunted.

Greenfield filter inferior vena caval interruption is an effective approach for pulmonary embolism prophylaxis. Serious complications, however, have been documented following migration of these filters. We report a case of Greenfield filter migration to the right side of the heart. Evaluation of these filters, as well as indications for retrieval, are discussed.

Protected specimen brush (PSB) is considered to be one of the standard methods for the diagnosis of ventilator-associated pneumonia, but to our knowledge, intraindividual variability in results has not been reported previously.

Acute rupture of the interventricular septum is a relatively unusual complication following acute myocardial infarction. The echocardiographic features depicted by transthoracic echocardiography are well described. However, transesophageal echocardiographic description of a ruptured septum has not been previously reported. This brief report illustrates the transesophageal features of such a defect.

Wegener's granulomatosis may present with a variety of findings and be difficult to diagnose. We report a case of a 55-year-old woman presenting with right middle lobe obstruction who was found to have limited Wegener's granulomatosis. Extensive medical evaluation was nondiagnostic and open lung biopsy specimens were required to establish the diagnosis.

The diagnostic yield of bronchoalveolar lavage (BAL) for Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus has been reported to be 95 percent, but falls to 62 percent in patients receiving aerosolized pentamidine. Because aerosolized pentamidine appears to be preferentially deposited in the middle and lower lobes, we postulated that an upper lobe lavage would have a higher diagnostic yield than the standard middle/lower lobe lavage in patients receiving aerosolized pentamidine. Twenty-five patients receiving aerosolized pentamidine suspected of having acute PCP underwent separate BAL of an upper lobe and lower lobe as well as transbronchial biopsy. Fifteen of the 25 (60 percent) were diagnosed as having PCP. Of the 15, one had the samples inadvertently combined. In the remaining 14, BAL was positive for P carinii organisms in 12 lavages of the lower lobe and 14 of the upper lobe. Upper lobe lavage had statistically significantly more P carinii organisms by semiquantitative technique than the lower lobe. In patients receiving aerosolized pentamidine, who develop acute PCP, an upper lobe lavage may have a higher diagnostic yield than the standard middle/lower lobe lavage. In addition, the transbronchial biopsy specimen offered no treatable diagnosis that was not made by lavage alone in the 25 patients. This raises the question of the utility of transbronchial biopsies in these patients.