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From a conceptual standpoint, the tests of pulmonary function can be divided into those that assess the ventilatory function of the lungs and those concerned with gas exchange. Tests of ventilatory function reflect alterations of the elastic resistance and flow resistance of the respiratory apparatus. The elastic properties of the lungs are assessed by determining the position and shape of the curve representing the relationship between the pressure across the lungs and absolute lung volume. When there is reduced distensibility of either the lungs or the chest wall, the volume-pressure curve is shifted down and to the right. The slope of the curve is reduced in the patient with pulmonary fibrosis, while it is normal in the patient with obesity. In asthma (or chronic bronchitis) and emphysema, the volume-pressure curve is shifted up and to the left. In emphysema, the slope of the curve is increased, while it is normal in patients with asthma or bronchitis. In practice, lung volume is used as an index of alterations of the volume-pressure characteristics of the lungs and/or chest wall. The vital capacity is often used as a surrogate for the TLC but it is lower than expected in both restrictive and obstructive disorders. The FEV1.0 reflects the degree of expiratory flow limitation. In a restrictive disorder, lung volume and the FEV1.0 are reduced, but the FEV1.0/FVC ratio is normal. In airflow limitation, lung volume, the FEV1.0, and the FEV1.0/FVC ratio are lower than expected. In airflow limitation, the reversibility with inhaled bronchodilator should be determined. Tests of airway responsiveness are indicated when evaluating patients with unexplained chronic cough, chest tightness, or wheezing, particularly if other lung function tests are normal. The adequacy of gas exchange is assessed by determining the arterial blood gas tensions--PaO2 and PaCO2--and the alveoloarterial pO2 gradient--P(A-a)O2. A lower-than-expected PaO2 can result from several different physiologic disturbances. When alveolar hypoventilation is the sole disturbance, the oxygen in the alveoli and in the blood perfusing them virtually comes into equilibrium, so that the P(A-a)O2 is normal. An elevated P(A-a)O2 is caused by either mismatching of ventilation and perfusion, true venous admixture, a diffusion abnormality, or a combination of these disturbances. Because dyspnea on exertion is a cardinal symptom of respiratory disease, exercise tolerance should be assessed. A reduced exercise tolerance may result from ventilatory limitation, impaired gas exchange, cardiac impairment, impaired delivery of the oxygen to the working muscles, or an inability to use the energy.
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PMID:Evaluation of respiratory function in health and disease. 160 91

Recent studies have used preoperative cardiopulmonary exercise testing to improve risk assessment of pulmonary resection for lung cancer. These studies have demonstrated inconsistent correlation between peak oxygen uptake (VO2) and postoperative complications but have not systematically examined other methods of risk stratification. We analyzed the findings in 42 patients who had cardiopulmonary exercise testing prior to lung cancer resection. Preoperative clinical data combining pulmonary factors (obesity, productive cough, wheezing, tobacco use, ratio of the forced expiratory volume in 1 s over the forced vital capacity [FEV1/FVC] < 70 percent, and PaCO2 > 45 mm Hg), and an established cardiac risk index were used to generate a cardiopulmonary risk index (CPRI). When analyzed using the risk index, the incidence of postoperative complications increased with higher CPRI scores. Those with a CPRI of 4 or greater were 22 times more likely to develop a complication, compared to a CPRI of less than 4 (p < 0.0001). We found that patients with a peak VO2 less than 500 ml/m2/min (body surface area) were 6 times more likely to experience a cardiopulmonary complication (p < 0.05). With multiple logistic regression analysis, peak VO2 was not an independent predictor of postoperative complications. Analysis also demonstrated that a CPRI of 4 or greater was associated with significant reductions in peak VO2. We conclude that both the peak VO2 during cardiopulmonary exercise testing and a multifactorial CPRI are highly predictive of complications after lung resection. Adding the peak VO2 did not enhance the risk estimation generated by the CPRI. The association between postoperative complications and peak VO2 may be explained by the correlation between identifiable cardiopulmonary disease (CPRI) and reduced oxygen uptake with exercise.
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PMID:Predicting complications after pulmonary resection. Preoperative exercise testing vs a multifactorial cardiopulmonary risk index. 836 78

We investigated symptoms suggestive of swallowing problems in patients with primary biliary cirrhosis, some of whom displayed features of sicca complex. A prospective study of 95 consecutive patients with primary biliary cirrhosis was conducted at a single teaching hospital using a questionnaire administered over the telephone. Some symptoms of sicca complex (dry mouth and/or dry eyes) were found in 65 patients (68.4%). Subjective xerostomia alone was present in 45 patients (47.4%). The questionnaire revealed an increase in incidence of dysphagia in xerostomia subjects, affecting 21 of 45 patients, compared with 6 of 50 non-xerostomia patients. Multivariate logistic regression analysis showed that confounding factors such as age, obesity, cigarette smoking, and medications associated with a dry mouth could not explain these findings. Twenty-eight patients complained of hoarseness, 23 of coughing, and 14 of wheezing, all of which were significantly more frequent than in the 50 patients without xerostomia. Heartburn affected 17 xerostomia patients and 15 non-xerostomia patients, indicating no difference in frequency between these two groups, even after age, obesity, cigarette smoking, and medications associated with heartburn were considered in the multivariate analysis. Acid regurgitation, nausea, and vomiting were also similar in frequency between patients with and without xerostomia. Swallowing problems, manifested primarily as dysphagia, are common in primary biliary cirrhosis patients who have subjective xerostomia.
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PMID:Primary biliary cirrhosis, sicca complex, and dysphagia. 919 Jan 3

Some studies suggest that socio-economic status (SES) inequalities in health are smaller in women than men, but the evidence is inconsistent as to whether this applies across various health measures and life stages. The first aim of this paper was to establish whether the magnitude of social inequality in health differs for men and women during early adulthood, specifically in respect to self rated health, limiting long-standing illness, psychological distress, respiratory symptoms, asthma/wheezing, height and obesity; second, to determine whether explanations for socioeconomic inequality in poor self rated health differ for men and women. Analyses are based on longitudinal data from the British 1958 birth cohort study using information from birth to age 33. When gender differences in inequalities were examined using social class, no significant differences emerged across the seven health measures examined at ages 23 and 33. SES inequalities based on education, however, showed greater inequality among men at age 33 for limiting long-standing illness and respiratory symptoms, but greater inequality among women for poor rated health at age 23 and psychological distress at age 33. Hence, gender differences in the magnitude of health inequality were inconsistent across age and health measures. An analysis of the contribution of explanatory factors to social class differences in self-rated health suggested that causes of inequality were similar for men and women. However, some discrepancies emerged, notably in the greater contribution of job insecurity to class differences for men and in the greater contribution of age at first child for women. The magnitude and explanations for gender differences in SES health inequalities are likely to vary according to life stage and health measure.
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PMID:Social inequalities in health: are there gender differences? 1004 37

Objective: To determine factors affecting sleep disturbances in children.Background: Factors affecting sleep disturbances have been studied extensively in adults, but relatively few studies have been done in children.Methods: As part of the twelfth survey of the Tucson Epidemiologic Study of Obstructive Airways Disease (TESOAD, 1991-1992), children, ages 3-14, of adult cohort members were administered a health questionnaire which contained items related to sleep problems as well as items related to respiratory diseases and symptoms. Participants were classified as having sleep disturbances if they reported disorders of initiating and maintaining sleep (DIMS), excessive daytime sleepiness (EDS) or snoring. Potential factors affecting sleep included age, gender, obesity, asthma, other bronchial problems, cough and sputum production, wheezing and rhinitis.Results: The overall prevalence rates were 16.8, 4 and 22.9% for DIMS, EDS, and snoring, respectively. We found a significantly higher prevalence of DIMS in 11-14-year-old girls (30.4%) and snoring (32.3%) in 3-6-year-old boys. Certain respiratory factors were more prevalent in children with sleep disturbances. Multivariate analysis revealed that risk factors for DIMS included female gender, age 11-14 and wheezing. The risk for EDS was increased in those children with cough and sputum production. Cough and sputum production also were risk factors for snoring as was rhinitis and age 3-6.Conclusions: We conclude that in children as in adults, respiratory symptoms are associated with sleep disturbances. Further, the increased insomnia seen in adult women may begin in early adolescence.
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PMID:Factors affecting sleep disturbances in children and adolescents. 1076 52

Reversible airway obstruction in childhood includes two major groups of patients: those with recurrent wheezing following bronchiolitis in early childhood, and those with allergic asthma, which represents an increasingly large proportion of cases through the school years. Over the last 40 years of the 20th century, allergic asthma has increased in many countries and in relation to several different allergens. Although this increase has differed in magnitude in different countries and also in the social groups most affected, it has had several features in common. The increase generally started between 1960 and 1970, has been progressive since then, and has continued into the 1990s without a defined peak. Among children 5-18 years of age, the increase has predominantly been among allergic individuals. Theories about the causes of the increase in asthma have focused on two scenarios: a) that changes in houses combined with increased time spent indoors have increased exposure to relevant allergens, or b) that changes in diet, antibiotic use, immunizations, and the pattern of infections in childhood have led to a change in immune responsiveness such that a larger section of the population makes T(H)2, rather than T(H)1 responses including IgE antibodies to inhalant allergens. There are, however, problems with each of these theories and, in particular, none of the proposed changes can explain the progressive nature of the increase over 40 years. The fact that the change in asthma has much in common with epidemic increase in diseases such as Type II diabetes or obesity suggests that similar factors could be involved. Several lines of evidence are reviewed that suggest that the decline in physical activity of children, particularly those living in poverty in the United States, could have contributed to the rise in asthma. The hypothesis would be that the progressive loss of a lung-specific protective effect against wheezing has allowed allergic children to develop symptomatic asthma. What is clear is that current theories do not provide either an adequate explanation of the increase or a practical approach to reversing the current trend.
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PMID:Specific and nonspecific obstructive lung disease in childhood: causes of changes in the prevalence of asthma. 1093 91

The possibility of a causal relationship is suggested by recent concomitant increases in the prevalence of obesity and asthma. In a general population sample, prevalence and incidence of asthma symptoms, skin tests, and body mass index (BMI) were ascertained at mean ages of 6.3 (n = 688) and 10.9 (n = 600) yr. Lung function, bronchodilator responsiveness, and daily peak flow variability were measured at 11 yr of age. There was no association between BMI at age 6 and wheezing prevalence at any age. Females, but not males, who were overweight or obese at 11 yr of age were more likely to have current wheezing at ages 11 and 13 but not at ages 6 or 8. This effect was strongest among females beginning puberty before the age of 11. Females who became overweight or obese between 6 and 11 yr of age were 7 times more likely to develop new asthma symptoms at age 11 or 13 (p = 0.0002); at age 11 their peak flow variability and bronchodilator responsiveness were significantly more likely to be increased. In females, becoming overweight or obese between 6 and 11 yr of age increases the risk of developing new asthma symptoms and increased bronchial responsiveness during the early adolescent period.
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PMID:Increased incidence of asthmalike symptoms in girls who become overweight or obese during the school years. 1137 99

Prediction formulae for sleep-disordered breathing can be useful for excluding a diagnosis, establishing an a priori probability of having a positive test, and for prioritizing patient testing. In general, prediction models have high sensitivity but low specificity. In a study analyzing the performance of four previously described prediction models, sensitivities ranged from 76% to 96%, specificities ranged from 13% to 54%, while positive predictive values ranged between 69% and 77%. The models were useful in identifying patients with a respiratory disturbance index of > or = 20 so that these patients could undergo alternative diagnostic testing strategies. The Berlin Questionnaire was tested in primary care settings and was able to identify high-risk patients fairly accurately. A regression neural network performed well with a sensitivity of 99%, a specificity of 80%, a positive predictive value of 88%, and a negative predictive value of 98%. In obese snorers, a regression model utilizing daytime arterial O2 saturation and specific respiratory conductance was effective for excluding obstructive sleep apnea (OSA). In congestive heart failure patients, risk factors for central sleep apnea include male gender, atrial fibrillation, age >60 years, and wake time PaCO2 <38 mm Hg. In children, risk factors for sleep apnea include obesity, African-American race, sinus problems, and persistent wheezing. There are also racial anthropomorphic differences in OSA patients, with whites having a tendency towards brachycephaly facial types (reduced anterior-posterior cranial dimension) and African-Americans having a tendency toward leptoproscopic facial types (longer facial height and decreased facial width). Further refinement of prediction formulae will improve diagnostic accuracy.
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PMID:Prediction formulae for sleep-disordered breathing. 1170 12

Although the association between obesity and asthma has been well documented, the nature of this association has yet to be clarified. The aim of this study was to examine the association of body mass index (BMI), lipid profiles, and atopy, wheezing, and lung function in older adults living in a rural area in Korea. BMI (kg/m2), lipid profiles, skin prick test, spirometry, and questionnaire including airway symptoms were obtained in a cross-sectional survey in 707 (259 males and 448 females) older adults (aged 50 to 93; mean, 65.7 yr) living in a high-altitude rural area in Korea. The prevalence of self-reported wheezing was 17.1% (121/707). The prevalence of atopy was 13.8%. The mean of BMI was 23.3+/-0.13 (14.6-32.8). The BMI was higher in females than in males (23.8+/-0.16 vs 22.4+/-0.17; p<0.01). The prevalence of wheezing was higher in group with BMI> or =25 than in group with BMI<25 [57/201 (28.3%) vs 64/505 (12.6%), p<0.01]. The BMI was higher in group with wheezing than in group without wheezing (24.3+/-0.34 vs 23.1+/-0.13, p<0.01). No association between BMI and atopy was found. These findings suggest that BMI associated with wheezing in older adults.
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PMID:High body mass index is associated with wheezing among older adults living in high-altitude area in Korea. 1217 42

Little is known about rates and predictors of remission of childhood asthma after the onset of puberty. We used data collected at ages 6, 8, 11, 13, and 16 years from the Tucson Children's Respiratory Study, a population-based birth cohort. The onset of puberty was defined as the age of appearance of the first pubertal signs as reported by parents. Information on wheezing both before and after onset of puberty (mean +/- SD follow-up from onset of puberty, 4.2 +/- 1 year) was available for 781 children. Of these, 166 had asthma (either frequent wheezing or a physician-confirmed diagnosis plus any wheezing) in at least one survey before puberty. In this group, 58% of the children (97 of 166) reported the presence of wheezing after the onset of puberty (unremitting asthma). In contrast, only 30% (39 of 131) of the children with infrequent wheezing before puberty experienced wheezing episodes after the onset of puberty (unremitting wheezing). In addition to frequent wheezing before puberty, obesity, early onset of puberty, active sinusitis, and skin test sensitization were significant and independent predictors of unremitting asthma after the onset of puberty. Our findings from a population-based longitudinal cohort challenge the commonly held view that asthma usually remits during adolescence.
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PMID:Persistence of asthma symptoms during adolescence: role of obesity and age at the onset of puberty. 1522 Jan 21


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