The precise roles of fiberoptic bronchoscopy (FOB) and computed tomography (CT) of the chest in the evaluation of patients presenting with hemoptysis have not been clearly defined. On the assumption that both procedures would likely provide unique and complementary information, a prospective study with blinded interpreters using a modified high-resolution CT technique (HRCT) and FOB was designed to evaluate 57 consecutive patients admitted to Bellevue Hospital with hemoptysis. Etiologies included bronchiectasis (25 percent), tuberculosis (16 percent), lung cancer (12 percent), aspergilloma (12 percent), and bronchitis (5 percent): in an additional 5 percent of cases, hemoptysis proved to be due miscellaneous causes, while in 19 percent hemoptysis proved to be cryptogenic. Patients with lung cancer all were at least 50 years old, smoked an average of 78 pack-years, and had less severe hemoptysis but of longer duration. All had conditions diagnosed both by HRCT and FOB. High-resolution CT proved of particular value in diagnosing bronchiectasis and aspergillomas, while FOB was diagnostic of bronchitis and mucosal lesions such as Kaposi's sarcoma. Fiberoptic bronchoscopy localized bleeding in only 51 percent of cases. The high sensitivity of CT in identifying both the intraluminal and extraluminal extent of central lung cancers in conjunction with its value in diagnosing bronchiectasis suggest that CT should be obtained prior to bronchoscopy in all patients presenting with hemoptysis.

Centrally mediated hypoventilation causes respiratory failure without respiratory distress. We present a case of recurrent acoustic neuroma at the cerebellopontine angle causing acute and chronic respiratory failure. Tumor resection eliminated recurrence of respiratory failure.

The purpose of this study was to assess the value of intrapleural urokinase (UK) instillations in enhancing tube drainage of loculated, complex pleural effusions. Tube thoracostomy has variable success in the treatment of complex pleural effusions, with limitations because of viscous fluid, improper tube position or kinking, and, most importantly, loculation. In the past, intrapleural administration of streptokinase has been used to lyse locules. In this study, eight patients with nine loculated pleural processes were treated with intrapleural instillations of UK. Six patients had previously undergone unsuccessful conventional tube drainage. Loculation was suggested by persistent fluid despite an adequate trial of simple drainage, radiographic demonstration of septation, or drainage of a volume of fluid far less than expected by a computed tomography scan. After instillation of a UK solution, the tubes were clamped for 30 to 180 min and then placed back to suction. Five pleural cavities with disease 6 to 18 days old showed complete resolution, and clinical improvement occurred. Three pleural processes showed improvement and one showed no improvement, with disease ranging from 23 days to 3 months. No complications were seen. These results suggest that UK instillations may enhance tube drainage of loculated pleural fluid in the early phase, before fibrosis has developed.

Since first described in 1984, nontraumatic pneumothoraces in patients with AIDS has become more common. When compared with spontaneous pneumothorax in the general population, pneumothoraces in patients with AIDS are often complicated by prolonged air leaks as well as higher recurrence rates. Chemical pleurodesis has an important role in the management of these complications. The most experience with chemical pleurodesis uses tetracycline hydrochloride as the sclerosing agent; however, this agent is no longer available. Doxycycline has been used in pleurodesis of malignant effusions, but its use in managing pneumothoraces is limited. We present five patients who have AIDS with a total of seven pneumothoraces. Each patient experienced a persistent air leak. Six of the pneumothoraces were managed successfully with doxycycline. Although the follow-up period was limited, there were no recurrences noted and the only side effect seen was chest pain in four which was easily controlled with narcotics. Doxycycline sclerotherapy can be used effectively for pleurodesis in the management of nontraumatic pneumothorax in the patient with AIDS.

We recently observed a striking increase in multidrug-resistant tuberculosis (MDR-TB) among patients admitted to the Chest Service at Bellevue Hospital Center in New York. We reviewed the laboratory susceptibility test results of 4,681 tuberculosis (TB) cases over the past 20 years, Combined resistance to isoniazid and rifampin increased from 2.5 percent in 1971 to 16 percent in 1991 with higher rates noted for individual drugs. We reviewed the medical records of 100 patients with drug-resistant TB, finding that these individuals were predominantly less than 40 years of age, minority, male, jobless, undomiciled, with a high percentage of drug abuse and human immunodeficiency virus infection. We conclude that the epidemics of AIDS and TB are complicated by a third epidemic of MDR-TB. This third epidemic requires urgent attention to achieve more rapid diagnosis, to develop new therapeutic regimens, and to address the social and hospital environment ot care for these individuals.

To evaluate the clinical and radiographic features of pulmonary aspergillosis as they present in AIDS patients; in particular, to determine similarities and differences between Aspergillus infection in patients with AIDS vs those without AIDS.

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.