OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronchi in patients undergoing diagnostic bronchoscopy because of a unilateral radiological abnormality. It was hypothesized that abnormalities in the properties of mucus would be greater on the side with the lesion and that this would be most obvious in patients with unilateral lung cancer.PATIENTS AND METHODS: Bilateral paired samples of bronchial mucus were taken from 38 nonatopic patients (aged 59.8±12.6 years) including 16 nonsmokers, 14 current smokers and eight exsmokers (more than one year). Twenty of the 38 patients had a radiologically defined unilateral abnormality. Eight of these 20, including one nonsmoker, had lung cancer. The viscoelastic properties of the collected mucus were determined by magnetic microrheometry, and the analysis was carried out without knowledge of the histological diagnosis or source.RESULTS: The rheological properties of mucus strongly suggested which was the abnormal side. Within the group of 20 patients with a unilateral radiological abnormality, mucus from the side of the lesion had a lower value of the loss tangent, tan &#x3b4;100 (P=0.004), indicating greater mucus recoil. This is consistent with poor mucus cough clearability on the lesion side. All eight cancer patients fit this mucus rheological pattern with a lower value of tan &#x3b4;100 on the affected side (P=0.007). Four of the five other patients with a similar mucus abnormality were categorized as high cancer risk by other criteria, while six of seven patients with mucus that did not have this abnormality were considered to be lower risk. Based on the mucus analysis done at the time of the bronchoscopy, two of the &#x2018;noncancer&#x2019; patients initially designated as high risk had cancer detected after several months of follow-up. Only two of the 18 patients without a defined unilateral lesion fit the mucus &#x2018;cancer pattern&#x2019;.CONCLUSIONS: These findings are consistent with the hypothesis that either abnormalities in mucus properties may represent a risk factor for the development of lung cancer or that bronchial mucus abnormalities may be associated with products secreted by the tumours that, in turn, may suppress mucus clearance.

J Gustavo Zayas

Bruce K Rubin

Ernest L York

Dale C Lien

Malcolm King

Bronchial Mucus Properties in Lung Cancer: Relationship with Site of Lesion

OBJECTIVE: To compare the effectiveness of a more intensive educational intervention with a less intensive intervention on the ability of hospital pharmacists to be prepared to educate patients regarding inhaled device technique.DESIGN: Randomized controlled trial. Inhaler technique and knowledge were assessed pre-education, immediately after and three months after education by a research assistant blinded to the educational allocation.SETTING: Tertiary hospital pharmacy department.POPULATION STUDIED: Hospital-based pharmacists.INTERVENTION: A 1 h &#x2018;hands-on&#x2019; session with feedback (more intense education, MIE) or written materials describing inhaler use (less intense education, LIE).MAIN RESULTS: The change in overall score from pre-education to early posteducation for MIE was greater than for LIE (mean [95% CI]) (2.64 [1.27 to 4.01] versus 1.26 [0.05 to 2.47], P&#x3c;0.001). Assessment scores improved for all device demonstrations and general knowledge. The change in score from the pre-education to the late posteducation period was only slightly higher in the MIE group than the LIE group, a difference that was not statistically significant (1.78 [0.82 to 2.74] versus 1.22 [0.06 to 2.39], P=0.09). Scores in both groups were lower in the late posteducation period compared with the early posteducation period. Greater increases in total score in the immediate posteducation period were associated with a low baseline score and the MIE intervention.CONCLUSION: Individual coaching in inhaler technique produces greater improvement in inhaler knowledge among hospital pharmacists than provision of written materials. However, the advantage of the more intensive intervention was short-lived, with little advantage evident in three months.

Cynthia Anne Jackevicius

Kenneth R Chapman

Inhaler Education for Hospital-Based Pharmacists: How Much Is Required?

Louis-Philippe Boulet

Allan Becker

Denis B&#xe9;rub&#xe9;

Pierre Ernst

Robert Beveridge

1998 Revision of the Canadian Asthma Consensus Guidelines

Pulmonary complications occur in an estimated 0.21% of patients with inflammatory bowel disease. The most common presentation of pulmonary manifestations is large airway disease, such as tracheobronchitis, chronic bronchitis or bronchiectasis. Small airway disease, such as constrictive bronchiolitis or bronchiolitis obliterans with organizing pneumonia, is less frequently reported, and is described as occurring in isolation from large airway disease. A case of a postcolectomy ulcerative colitis in a patient who has both large airway involvement, tracheobronchitis and bronchiectasis, and constrictive bronchiolitis is presented.

Heather Ward

Kendra L Fisher

Ranjit Waghray

Jody L Wright

Sharon E Card

Donald W Cockcroft

Constrictive Bronchiolitis and Ulcerative Colitis

Occupational asthma is typically associated with an eosinophilic bronchitis. The case of a 41-year-old woman who developed symptoms of asthma after occupational exposure to metal working fluids is reported. The diagnosis of asthma was confirmed by an forced expiratory volume in 1 s (FEV1) of 1.7 (59% predicted), with 11% reversibility after inhaled bronchodilator and a provocation concentration of methacholine to cause a fall in FEV1 of 20% (PC20) of 0.4 mg/mL. Induced sputum examination showed a marked neutrophilia. Over the next six months, serial sputum analyses confirmed the presence of a marked sterile neutrophilic bronchitis during periods of occupational exposure to metal working fluids, which resolved when the patient was away from work and recurred when she returned to work. The sputum findings were mirrored by corresponding changes in spirometry and PC20 methacholine. The findings indicate the occurrence of occupational asthma associated with an intense, sterile neutrophilic bronchitis after exposure to metal working fluids.

Richard Leigh

Frederick E Hargreave

Occupational Neutrophilic Asthma

Leukotrienes (LTs), lipid mediators of inflammation, have proved to be important biochemicals involved in the symptoms and physiological changes of asthma. In the past year and a half, the development of three new drugs that modulate the LT pathway has been completed. The first subclass of these drugs, leukotriene receptor antagonists (LTRA) (zafirlukast and montelukast), blocks the interaction of the cysteinyl form of the LTs with the cell type bearing the receptor. The second subclass, the 5-lipoxygenase (5-LO) inhibitors (zileuton) inhibits the 5-LO enzyme, which prevents the formation of both cysteinyl LTs and LTB4. The LT modulators have shown efficacy in inhibiting the physiological changes occurring after allergen, acetylsalicylic acid and exercise challenge in asthmatics. In addition, they have shown efficacy in improving symptoms, beta-agonist use and forced expiratory volume in 1 s (FEV1) in chronic, &#x2018;day-to-day&#x2019; asthma in patients with mild disease. Comparison studies with low doses of inhaled corticosteroids suggest that LT modulators may have similar effects on symptom scores and beta-agonist use, but have lesser effects on FEV1. Finally, emerging data suggest that these drugs are beneficial in decreasing the dose of inhaled corticosteroids necessary to control more moderate to severe asthma. While long term studies will be helpful in determining the &#x2018;disease modifying&#x2019; effects of these drugs, data suggest that these drugs are useful in the treatment of a broad range of asthmatic patients.

Sally E Wenzel

Leukotriene Receptor Antagonists and Related Compounds

OBJECTIVE: To review the literature on the surgical treatment of emphysema and to present preliminary results from a pilot study of lung volume reduction (LVR) surgery.DESIGN: Case series of consecutive patients referred for LVR surgery. Outcomes were quality of life, pulmonary function and exercise capacity.SETTING: Two university-affiliated hospitals in Ontario.POPULATION STUDIED: Patients between the ages of 40 and 75 years with emphysema who had severe airflow limitation, hyperinflation of the lungs and impaired quality of life.INTERVENTION: Bilateral reductions with multiple wedge resections of the lung using a linear stapling device with bovine pericardial buttressing were completed via a median sternotomy.MAIN RESULTS: Of 50 patients referred, 24 underwent LVR surgery. Mean age of the cohort was 63 years. Operative 30-day or in hospital mortality was 8%. Two other patients (8%) died from respiratory failure after LVR within the first year. Postoperative complications included prolonged air leaks (six of 24), tracheobronchitis (five of 24), mechanical ventilation (four of 24) and pneumonia (three of 24). Mean length of stay was 18 days (median 12 days). At one year, there was a sustained decrease in total lung capacity from 133% to 123% predicted. There were improvements in forced expiratory volume in 1 s, from 22% of predicted preoperatively to 32% postoperatively, and in 6 min walk performance, from 345 to 381 m. Improvements were also noted in the quality of life assessments.CONCLUSIONS: Preliminary results suggest that LVR surgery is feasible and may improve the patient&#x2019;s quality of life, pulmonary function and exercise capacity. A randomized clinical trial comparing LVR plus the best medical management with the best medical management alone is currently underway to determine the effectiveness of LVR.

John D Miller

Richard A Malthaner

Charles H Goldsmith

Gerard Cox

David Higgins

David Stubbing

Allan Kitching

Toni E Newman

Ellen McDonald

Lung Volume Reduction for Emphysema and The Canadian Lung Volume Reduction (CLVR) Surgery Project

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Canadian Respiratory Journal provides a multidisciplinary forum for research in all areas of respiratory medicine. The journal publishes research related to asthma, allergy, COPD, non-invasive ventilation, therapeutic intervention etc.

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Chief Editor, Dr Alice M Turner, is based at the University of Birmingham, UK. Her main research interests are the clinical aspects of alpha 1 antitrypsin deficiency and chronic obstructive pulmonary disease.

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Canadian Respiratory Journal - Table of contents 1999

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Canadian Respiratory Journal provides a multidisciplinary forum for research in all areas of respiratory medicine. The journal publishes research related to asthma, allergy, COPD, non-invasive ventilation, therapeutic intervention etc.

Canadian Respiratory Journal