EMPHYSEMA PATIENTS MAY BENEFIT FROM LVRS

In a recent trial, lung volume reduction surgery (LVRS) improved pulmonary function for three years in nine of 26 elderly patients with end-stage emphysema. Seven of these patients continued to show improvement at four years. Of all the baseline measurements obtained, only vital capacity and forced vital capacity could differentiate the patients who continued to have ongoing improvement, the study authors reported in Chest.

At study entry, all 26 patients (mean age, 67 years) were able to walk 100 yards or less (dyspnea grade 3 or higher), and 18 required full- or part-time oxygen supplementation. Computed tomographic (CT) scans showed severe emphysematous destruction, primarily in the upper and middle lung fields.

The patients underwent sequential, bilateral, stapled LVRS using video-assisted thoracoscopy. Approximately 20% to 30% of each lung was removed.

Mortality increased dramatically with time over the four years of the study (Table 1). However, the mortality rates in this study are consistent with or lower than those found in previous studies of emphysema patients with a similar level of impairment who did not undergo surgery.

LVRS also produced marked improvements in both symptoms and measurements of pulmonary function (Table 1). The improvement in expiratory airflow and hyperinflation found in this study "is related to the increase in lung elastic recoil pressure and its secondary effect on increasing small airway diameter," the researchers noted.

Eighteen patients required oxygen supplementation at baseline. LVRS eliminated oxygen dependence in 78% of the patients at one year, in 50% at two years, in 33% at three years, and in 22% at four years.

In the nine patients who experienced long-term improvement, baseline measurements of vital capacity and forced vital capacity were significantly higher than they were in the 10 patients who died within four years of surgery. Although these measurements appeared to have predictive value, "the importance of heterogeneous distribution of emphysema on lung CT and perfusion scans in choosing potential LVRS candidates must still be emphasized," the researchers explained.

Gelb AF, McKenna RJ Jr, Brenner M, et al. Lung function 4 years after lung volume reduction surgery for emphysema. Chest. 1999;116:1608-1615.

MENTAL HEALTH OF CARETAKER, CHILD AFFECTS ASTHMA

The mental health of inner-city children and their caretakers significantly affects asthma morbidity, according to findings published in a recent issue of Pediatrics. "Intervention programs targeted at improving asthma management may fail if they ignore the psychosocial factors that facilitate or impede the family's ability to carry out medical management plans," the study investigators concluded.

The findings are based on data from 1,260 asthmatic children ages 4 to 9 years who were enrolled in the National Cooperative Inner-city Asthma Study. The children were recruited from seven metropolitan areas in the United States. Psychosocial variables were assessed at baseline and asthma symptoms were evaluated at baseline and at three, six, and nine months.

Of the psychosocial factors assessed in this study, the caretaker's mental health was the strongest predictor of asthma-associated hospitalizations. An almost twofold risk of hospitalization was found among children whose caretakers exceeded the clinical cutoff on the Brief Symptom Inventory. In contrast, the children's functional status and days of wheeze were not strongly related to the risk of hospitalization.

In addition, asthma symptoms were directly related to the children's mental health. Specifically, children who scored above the clinical cutoff on the Achenbach Child Behavior Checklist had an additional 18 days of wheeze per year and scored 4 points lower on a measure of functional status.

Weil CM, Wade SL, Bauman LJ, et al. The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics. 1999; 104:1274-1280.

REDUCING THE RISK OF AIDS-RELATED OPPORTUNISTIC ILLNESSES

Potent antiretroviral therapy reduces the incidence of opportunistic illnesses in patients infected with the human immunodeficiency virus (HIV), according to data from the Swiss HIV Cohort Study. A low baseline CD4 cell count was the strongest predictor of disease progression after initiation of antiviral therapy and may be used to detect patients who require close clinical surveillance.

Ledergerber et al examined the effects of potent antiretroviral therapy (ie, at least three antiretroviral drugs, including a protease inhibitor) among 2,410 HIV-infected patients. Each subject was followed for at least 15 months after the start of treatment.

The incidence of opportunistic illnesses per 100 person-years decreased from 15.1 in the six months before therapy initiation to 7.7 in the first three months after the treatment's start, 2.6 in the next six months, and 2.2 between nine and 15 months. This decrease ranged from a 38% reduction per month for Kaposi's sarcoma to a 5% reduction per month for non-Hodgkin's lymphoma.

Compared with the rest of the cohort, patients with a low baseline CD4 cell count, a high baseline viral load, advanced clinical stage, or older age had a significantly increased risk of opportunistic illness after starting antiretroviral therapy. Of these variables, baseline CD4 cell count was the best predictor of disease progression, with an almost threefold increased risk for cell counts of 51 to 200 X 10⁶/L and an almost sixfold increased risk for cell counts of 50 X 10⁶/L or below (the comparison was with cell counts above 200 X 10⁶/L).

Furthermore, two factors--a CD4 cell count that rose by 50 X 10⁶/L or more and undetectable levels of HIV-1 RNA in plasma (fewer than 400 copies/mL)--were associated with a markedly lower risk of an opportunistic illness after the initial six months of antiretroviral therapy (hazard ratios, 0.32 and 0.39, respectively).

Ledergerber B, Egger M, Erard V, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA. 1999;282:2220-2226.

RAMPANT MISUSE OF ASTHMA MEDICATIONS

Results from a large survey reveal that 16% of patients who use inhaled ß-agonists overuse these drugs and that 64% of patients who use inhaled corticosteroids underuse their medication.

Diette et al examined data from the Managed Health Care Association Outcomes Management System Consortium Asthma Study, which included 6,612 health plan enrollees (age 18 and older) with asthma.

Among the 5,718 patients with moderate or severe asthma, 94% reported using inhaled ß-agonists for short-term asthma relief, and 67% took inhaled corticosteroids for long-term management. However, 16% of the patients receiving ß-agonists reported overuse (more than eight puffs per day on days of use), and 64% of the inhaled corticosteroid recipients reported underuse (four or fewer puffs per day or use on four or fewer days per week).

Both patient and provider characteristics were found to influence medication misuse. Patient characteristics associated with overuse or underuse are listed in Table 2. Overuse of ß-agonists was significantly less likely to occur among patients of allergists than among patients of generalists, but was more likely to occur among patients of pulmonologists. In addition, the study found that underuse of inhaled corticosteroids was significantly more likely to occur among patients treated by generalists than among patients treated by the other two physician types.

Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids. Arch Intern Med. 1999;159:2697-2704.

REHABILITATION PROGRAM FOR CHRONIC LUNG DISEASE

A six-week multidisciplinary pulmonary rehabilitation program offers long-term benefits for patients with disabling chronic lung disease. In a recent randomized controlled trial, rehabilitated patients showed greater improvements in walking ability and health status compared with patients who received standard treatment. These benefits, which persisted for at least one year, translated into a decreased use of health services.

Griffiths et al randomized 200 patients to a multidisciplinary rehabilitation program or to standard medical care for six weeks and followed these patients for a year. The patients had chronic obstructive bronchitis, emphysema, or chronic poorly reversible asthma or bronchiectasis.

The rehabilitation program consisted of two-hour sessions devoted to educational activities, an exercise program aimed at achieving 30 minutes of exercise, and a teaching portion that looked at psychological issues relating to chronic disability. These sessions were conducted three times a week.

During the one-year follow-up, the number of patients admitted to the hospital in each of the two groups was similar (about 40), but the mean number of days these patients spent in the hospital was significantly shorter in the rehabilitation group (10.4 days vs 21 days in the control group). The rehabilitation group also had significantly greater improvements in walking ability and health status both at the end of the six-week period and after one year, compared with the control group.

Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355:362-368.

PNEUMOCOCCAL VACCINE EFFECTIVE IN AATD PATIENTS

New findings suggest that pneumococcal vaccination should be recommended for patients with alpha1-antitrypsin deficiency (AATD)--a population at increased risk for respiratory infections. The majority of AATD patients enrolled in a recent study reported in Chest had a preserved antibody response against pneumococcal polysaccharides following vaccination.

The study was designed to compare the specific immunoglobulin G (IgG), IgG1, and IgG2 antibody responses to the 23-valent pneumococcal vaccine. The study group included 18 patients with homozygous proteinase inhibitor phenotype Z AATD and 40 healthy controls. Nine AATD patients had bronchiectasis; four had a history of recurrent pneumonia. Blood samples were taken just before and 21 days after vaccine administration.

The mean increases in serum concentrations of total IgG, IgG1, and IgG2 showed no significant between-group differences, which indicates that the antibody response is preserved in AATD patients. However, the AATD patients with bronchiectasis tended to have higher IgG subclass concentrations but lower postimmunization antipneumococcal antibody levels than did either the controls or the AATD patients without bronchiectasis. This suggests that patients with decreased postimmunization antipneumococcal titers may be at increased risk for development of bronchiectasis, even if their serum IgG levels are normal or increased, the researchers noted.

In this study, two AATD patients with a history of recurrent pneumonia were considered nonresponders. A third AATD patient with a history of recurrent pneumonia did not exhibit an IgG2 response but did have normal IgG and IgG1 responses. These findings and data from previous studies suggest that an absent IgG2 response may be associated with an increased risk for recurrent pneumonia. "We suggest that patients with recurrent pneumonia should have their IgG2 serum levels tested and, if normal, should be investigated for a deficient IgG2 specific antibody response against polysaccharides," the researchers observed.

Miravitlles M, de Gracia J, Rodrigo MJ, et al. Specific antibody response against the 23-valent pneumococcal vaccine in patients with [alpha]1-anti-trypsin deficiency with and without bronchiectasis. Chest. 1999;116:946-952.

FUNCTIONAL AIRWAY OBSTRUCTION CAN MIMIC TONGUE ANGIOEDEMA

Tongue swelling leading to upper airway obstruction in a 12-year-old girl was determined to be a conversion reaction rather than angioedema, according to a recent case reported in the Annals of Allergy, Asthma, & Immunology. "The findings in this case suggest that even abnormal physical and radiographic findings can be present in functional airway obstruction," the study investigators concluded.

The girl initially presented with a sore throat and ear pain without fever. Later, her throat pain worsened, she had difficulty swallowing, and her voice became weak. She was hospitalized for two days and treated with ß₂-agonist bronchodilators, antihistamines, corticosteroids, and cefprozil. However, the day following discharge, she presented to an emergency department with breathing difficulties, swelling under the chin, and a weak voice. In spite of her condition, the researchers noted that she was calm, cooperative, and did not appear to be in distress.

Severe, posterior-third tongue swelling was found on lateral neck radiograph, and soft tissue fullness at the base of the tongue with no associated lymphadenopathy was found on computed tomography. She underwent direct laryngoscopy and biopsy of the tongue base; tongue biopsies were normal. Interestingly, "with anesthetic induction, there was complete relaxation of the upper airway with no evidence of tongue swelling, masses, or other abnormalities," the researchers explained.

Following surgery, she had no further evidence of tongue mass or breathing difficulties. Her primary care physician noted that the girl acted "unusual" during office visits and that the "dynamics between her family were odd."

Functional airway obstruction commonly occurs in young female adolescents under psychological stress or with a history of respiratory problems, the researchers explained. "The term la belle indifference has been used to describe the lack of concern the patient demonstrates to the respiratory distress," they added. These patients do not respond to medications and usually benefit from relaxation techniques, neck extension, and verbal support. The diagnosis "is one of exclusion and should be considered if other causes of airway obstruction are excluded," the researchers concluded.

Nordness ME, Zacharisen MC. Functional airway obstruction mimicking tongue angioedema. Ann Allergy Asthma Immunol. 1999;83:540-542.