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"Cor pulmonale" is a classic feature of the "Pickwickian syndrome". Earlier studies have reported a high prevalence of pulmonary hypertension (PH) in obstructive sleep apnoea (OSA) patients, but this has not been confirmed by recent studies with a more adequate methodology, including larger groups of patients. The first part of this review is devoted to the prevalence of PH in OSA; most recent studies agree on prevalence of 15-20%. The second (and major) part of the study deals with the causes and mechanisms of PH in OSA. Pulmonary hypertension is rarely observed in the absence of day-time hypoxaemia, and the severity of nocturnal events (apnoea index (AI), apnoea+ hypopnoea index (AHI) does not appear to be the determining factor of PH. Diurnal arterial blood gas disturbances and PH are most often explained by the presence of severe obesity (obesity-hypoventilation syndrome) and, principally, by association of OSA with chronic obstructive pulmonary disease (the so called "overlap syndrome"). Bronchial obstruction is generally of mild-to-moderate degree and may be asymptomatic. The final part of the review analyses the therapeutic consequences of the presence of PH in OSA patients. Pulmonary hypertension, which is generally mild-to-moderate, does not need a specific treatment. When nasal continuous positive airway pressure (CPAP) fails to correct sleep-related hypoxaemia, supplementary oxygen must be administered. In patients with marked daytime hypoxaemia (arterial oxygen tension (Pa,O2), < or = 7.3 kPa (55 mmHg) conventional O2 therapy (nocturnal + diurnal) is required.
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PMID:Pulmonary hypertension in the obstructive sleep apnoea syndrome: prevalence, causes and therapeutic consequences. 872 47

The aim of this study was to compare the quality of life of patients under home mechanical ventilation (HMV) for restrictive lung disease, with the quality of life of patients with chronic obstructive pulmonary disease (COPD), having similar decrease in forced expiratory volume in one second (FEV1), but not receiving HMV. Sixteen patients who were receiving intermittent HMV (six post-tuberculosis, four post-poliomyelitis, two neuromuscular diseases, two kyphoscoliosis, two obesity-hypoventilation syndromes) were compared to 15 COPD patients who were receiving only usual conservative treatment, including long-term oxygen therapy. Dyspnoea scores, anxiety, depression, and psychosocial scores, as well as a panel of functional parameters were measured. The two groups did not differ in terms of functional impairment. However, patients under HMV had much better scores for anxiety, depression, and adjustment to illness than COPD patients. Scores for dyspnoea at rest were also better in the HMV group, but showed no relationship to quality of life. In spite of a cumbersome and intrusive type of treatment, patients under home mechanical ventilation for predominantly restrictive lung disease were found to have a better quality of life than chronic obstructive pulmonary disease patients under conservative therapy. In the first group, a longer history of coping with a chronic disease and the perception that medical intervention is effective may in part account for this difference.
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PMID:Quality of life of patients under home mechanical ventilation for restrictive lung diseases: a comparative evaluation with COPD patients. 876 89

In this retrospective investigation we carried out a thorough physical examination, ventilation/perfusion scintigraphy, echocardiography and lung function test in 19 of all 21 long-term survivors consecutively operated on for massive pulmonary embolism between 1968 and 1992. Two patients refused these investigations but were both asymptomatic. The mean follow-up was 8.4 years and 12 (57%) of the patients were in NYHA I and 6 (29%) in NYHA II. The three patients in NYHA III (there were none in class IV) underwent right heart catheterization and pulmonary angiography additionally. Our findings suggest that, generally, the results of scintigraphy, echocardiography, lung function tests and physical examination correspond to the subjective status expressed as NYHA (dyspnea) class, when evaluated in combination. However, in classes III and IV other causes of dyspnea apart from residual pulmonary vascular obstruction can be found. These may also occur in combination. We observed severe chronic obstructive lung disease, hemidiaphragmatic paralysis, obesity, pulmonary hypertension of unknown origin, atrial septal defect (ASD) and neurologic residual deficit with depressive state. Thus, in evaluating long-term results of pulmonary embolectomy with regard to vascular desobliteration, NYHA classification does not seem to be reliable for classes III and IV.
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PMID:Long-term follow-up in pulmonary embolectomy: is NYHA (dyspnea) classification reliable? 877 83

During surgical procedures, multiple physiologic changes affect the pulmonary system and its defense mechanisms. The presence of basic risk factors (eg, smoking, chronic obstructive pulmonary disease, severe obesity) can affect whether these physiologic changes result in pulmonary complications or even death. Therefore, the presence of risk factors should be ascertained in all patients before abdominal or thoracic surgery. The degree of risk can be further determined preoperatively by additional evaluation, such as pulmonary function testing, newer assessment of cardiorespiratory status, history taking, and physical examination. The presence of risk factors and the type of operation to be performed should guide decisions about whether to perform a procedure or to use prophylactic measures before and after surgery. New operative techniques may allow some procedures that were prohibited in the past to be performed in high-risk patients.
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PMID:Preoperative pulmonary evaluation. Identifying patients at increased risk for complications. 891 36

Nutritional counseling is a common primary care intervention but few empirical data are available. This study analyzed morbidity in family medicine practices and the relevance of nutritional counseling. Morbidity data from the Nijmegen University family medicine Continuous Morbidity Registration were studied. Since 1967 four practices (seven family physicians) have recorded all new episodes of illness. Physicians were trained and supervised monthly in their coding and classification of morbidity with diagnostic criteria. Two experienced family physicians assessed the nutrition sensitivity of all 400 diagnostic rubrics of the classification list. Incidence and prevalence of all morbidity and of nutrition-sensitive morbidity were calculated. The most common (chronic) diseases in family practice were a mixture of diseases of organ and body systems: hypertension, obesity, cardiovascular disease, chronic arthritis, asthma, chronic obstructive pulmonary disease, eczema, and diabetes mellitus. The prevalence of these diseases gradually increased in the past decade. Forty-eight diagnostic rubrics were considered to be nutrition sensitive, accounting for 16.5% of diagnoses recorded. Their prevalence also increased in the past decade. The survey supports the importance of nutrition-related interventions in family medicine but underlines that these interventions are directed at a variety of illnesses and patient groups. Common nutritional intervention techniques that can be applied in the personal care of patients in the context of their family life should be developed.
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PMID:Morbidity in family medicine: the potential for individual nutritional counseling, an analysis from the Nijmegen Continuous Morbidity Registration. 917 96

Sleep is characterized by many changes in the respiratory system, including a reduction in respiratory motor output associated with the loss of wakefulness, increased upper airway resistance, and blunted protective reflexes (such as load compensation), that result in reduced alveolar ventilation. The development of carbon dioxide retention appears to be linked to the exaggeration of sleep-related changes on ventilation by coexistent respiratory system disorders. Sleep-disordered breathing is becoming increasingly recognized in subjects with neuromuscular diseases, who may be prone to nocturnal respiratory events due to diaphragm and bulbar muscle weakness, abnormal central respiratory control, obesity, and sleep position restrictions. Nocturnal gas exchange deterioration may occur in patients with chronic obstructive pulmonary disease, particularly during rapid eye movement sleep when activity of the respiratory muscles other than the diaphragm is inhibited. Concurrent obstructive sleep apnea syndrome may further compromise nocturnal ventilation, thereby contributing to the development of acute or chronic respiratory failure. The use of noninvasive nocturnal ventilation at night has resulted in significant improvements in symptoms of hypoventilation and daytime carbon dioxide retention in various clinical settings, yet important questions remain about implementation of this modality.
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PMID:Sleep-wake cycles and the management of respiratory failure. 936 92

Nocturnal oximetry can show nocturnal oxygen desaturation. This examination was proposed as an investigation for the early detection of the sleep apnoea syndrome (SAS). We have compared the results of nocturnal oximetry and polysomnography in 329 consecutive patients seen in the department of thoracic medicine for the early detection of the SAS between June 1990 and June 1995. The diagnosis of SAS was confirmed at the time of polysomnography using an hypopnoea/apnoea index (IAH) greater or equal to 15 per hour. Two parameters of oximetry were well correlated with IAH less than 15 per hour: if the mean oxygen saturation is greater than 92% and for less than five per cent of the time of the examination there was a saturation of less than 90%. The sensitivity was 89.7% and the specificity was 57.8%. Among the 48 false positive cases on oximetry 17 patients were found to be suffering from COPD and 31 patients were probably suffering from a syndrome of upper airways resistance or possibly from the hypoventilation obesity syndrome. Amongst the 22 false, negatives to oximetry 10 non COPD patients with an IAH of greater than 30 per hour and diurnal somnolence had important anomalies of the oro-pharyngeal pathway as the origin of their nocturnal apnoea. The 12 other false negatives were patients with moderate SAS with an IAH of between 15 and 20 per hour. Logistical analysis has shown the association of the two oximetric criteria (mean oxygen saturation or percentage of time with a saturation of less than 5%) with clinical criteria (body mass index and formation on diurnal somnolence from a questionnaire) would enable a probable diagnosis of SAS in 75% of cases. Our study shows that nocturnal oximetry used an early diagnosis test, associated with clinical and respiratory function data enables the number of requests for polysomnography to be reduced.
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PMID:[Role of nocturnal oximetry in screening for sleep apnea syndrome in pulmonary medicine. Study of 329 patients]. 941 97

Minimally invasive cardiac surgery is rapidly gaining interest because of fast recovery, reduced morbidity, shorter hospital stay, lower costs, and better cosmetic results. Aortic valve surgery can be performed through a small (10- to 12-cm) transverse sternal incision, and femoro-femoral cannulation is used for cardiopulmonary bypass. Exposure of the ascending aorta is satisfactory. From 1 March through 30 September 1996, 7 patients underwent aortic valve replacement through this approach. The mean age of the 5 women and 2 men was 58.8 years. We used this technique mainly in patients with chronic obstructive pulmonary disease, diabetes, or obesity, in the absence of coronary artery disease. There was no mortality, nor was there reoperation for bleeding, stroke, or wound infection. All patients were extubated after 2 hours in intensive care and were discharged on the 4th postoperative day. Additional cases are needed to properly assess the correct indication and surgical technique.
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PMID:Aortic valve replacement through a minimally invasive approach. 945 90

The incidence of peri-operative pulmonary complications varies, depending on surgery and patient related determinants. Risk factors include upper abdominal or thoracic surgery, duration of anaesthesia, age, obesity, smoking history and underlying respiratory diseases such as COPD. The preoperative evaluation of patients undergoing general surgery is predominantly based on medical history and physical examination. A preoperative chest radiograph and pulmonary function tests are indicated in some high risk patient groups, and in all patients about to undergo lung resection surgery. If in this latter group, the preoperative lung function is severely compromised, a quantitative perfusion scan and exercise testing may be useful for the assessment of the operative risk. Prevention of postoperative pulmonary complications should begin with discontinuation of smoking at least 8 weeks prior to surgery. In high risk patients preoperative chest physiotherapy, including incentive spirometry, is clearly beneficial.
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PMID:Preoperative pulmonary evaluation. 948 24

Wound-related complications are common after incisional hernia repair. Prophylactic antibiotic use, placement of subcutaneous drains, and technical factors such as mesh implantation reportedly influence the incidence of these complications. Our aim was to study the incidence of wound complications in incisional hernia repairs and to determine whether use of antibiotics, drains, or mesh influence these rates. Two hundred fifty hernias were repaired in 206 patients over a 14-year period. Simple repair was performed in 151 patients while mesh was used in 99 repairs. Mesh repair was used in larger hernias, required longer operating time, and had greater blood loss than simple repair. Twenty-eight per cent of repairs with mesh were for recurrent hernias compared with 14 per cent for simple repair (P < .05). Overall, 34 per cent of patients had wound-related complications. Chronic obstructive pulmonary disease, obesity, steroid therapy, and previous wound infection were not associated with increased risk for wound complications. The use of mesh and hernia defect > 10 cm were associated with significantly more wound complications. The incidence of seroma was increased in mesh repairs (21% vs 7%), as were total wound complications (44% vs 26%; P < 0.05). A suprafascial onlay mesh technique resulted in more frequent seroma formation. Patients undergoing mesh repair were more likely to receive antibiotics (91% vs 71%) and have subcutaneous drains placed (57% vs 25%; P < 0.05) compared to simple primary repair. Neither antibiotics nor drains had an effect on the incidence of wound complications within each group. Overall, wound infections were more frequent when drains were placed. We conclude that repair of incisional hernias is associated with substantial risk of wound-related complications. Mesh is used for repair of larger and more complex hernias and is associated with increased risk of wound complications. Abnormal fluid collections are the most frequent problem, but the use of drains does not reduce the incidence of these complications.
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PMID:Factors affecting wound complications in repair of ventral hernias. 952 Aug 25


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