B J Lavins and D L Hamilos obstructive airway physiology. Distal airway bronchomalacia resulting in severe http://chestjournal.chestpubs.org/content/97/2/489.
Distal airway bronchomalacia resulting in severe obstructive airway physiology. B J Lavins and D L Hamilos Chest 1990;97;489-491 DOI 10.1378/chest.97.2.489 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/97/2/489
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1990by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
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obtaining
information about for typing and help
Janigan
the accident andJoy with the manuscript.
Douglas
Karen
and
Table
l-Pilmonary
Test Resulte,
Function Prebronchodilator
Measurement
1980
September Pbstbronchodilator
REFERENCES L (% pred) L (% pred)
FEy,, 1 Guidotti
TL.
The
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Res
1978;
15:443-72
2 Guidotti
TL.
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functional
3 Jones
higher
CR,
exposure
EP,
Hall
AT,
to nitrous
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of nitrogen
fumes.
doPico
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dioxide:
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JI.
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GA,
1973;
pulmonary
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RA,
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of acute
28:61-65
Dickie J Occup
Barbee
1.12 (35) 2.84 (80)
Nitrogen
HA. Med
1978;
chomalacia, not affecting the trachea or main-stem bronchi. She had been presumed to have severe steroid-dependent asthma and was referred to the National Jewish Center for Immunology and Respiratory Medicine (NJC).
20:
103-10 acid.
AJ,
JAMA
6 Crapo Hlth
Kropp
1955;
JD,
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of oxidants.
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Injury
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S.
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structure
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cell renewal in small airways. In: P, eds. Mechanisms in respiratory Florida: CRC Press, 1982:192 gases. Environ Health Perspect 1984; 55:
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MG,
in lung Dis
ozone
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injury.
Rinaldo
DF. and
Biochemical
nitrogen
and
dioxide
metabolic
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Am
changes Rev
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lung 11
Tierney
with
1978;
10 Till
PA.
Fed
JE.
Proc
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complement
1986;
Mediation
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acute
45:13-18
of ARDS
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Chest
1986;
89:
590-93 12
Bone
RC,
Jacobs
syndrome.
In:
respiratory 96
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Distal
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Resulting Airway MAJ
ER,
Balk
RC,
New
George York:
BA.
Adult RB,
respiratory
Hudson
Churchill
LD,
distress eds.
Livingston,
Acute
1987:173-
Bronchomalacia
in Severe Obstructive
Physiology*
Bernardj
Lavins,
MC,
USA;t
B report
at
the
age
of
woman 18,
she
was in excellent began
to
health
experience
until
1980,
dyspnea,
when,
occasional
wheezing, and a productive cough. Results of pulmonary function tests (PFFs) in September 1980 are shown in liable 1. Her respiratory symptoms progressively worsened and from 1982 through 1985 required frequent bursts of steroid therapy. She was hospitalized in both 1984 and 1985 for exacerbations of her respiratory condition. Both ofthese exacerbations responded poorly to seven days of aggressive bronchodilator therapy and IV methylprednisolone. Table 2 shows results of PVFs from the 1985 admission.
By 1986, the patient was receiving continuous steroids. Between October 1986 and May 1987, prednisone in doses of3O to 100 mg/ day failed to relieve the dyspnea. In May 1987, the patient was referred to NJC for evaluation. At that time, she complained of occasional wheezing, dyspnea after walking 15 to 22.5 m, and a chronic cough, occasionally productive ofwhite sputum. The patient had no history of childhood asthma and had had chronic rhinitis with a negative skin test in 1982 and 1985. She had been employed as a hairdresser from 1978 through 1982 and had smoked one pack of cigarettes per day for three years but quit in 1981. Her family history disclosed no respiratory diseases. Her medications on admission were theophylline, 300 mg four times daily; prednisone, 30 mg daily; albuterol inhaler, two puffs four times daily, and 0.5 ml ofnebuhzed isoetharine every 4 h. The physical examination results were normal except for a respiratory rate of 20 breaths/min, a pulse rate of 120 beats/mm, a appearance,
and
significantly
decreased
breath
sounds,
with soft expiratory and
Daniel
L. HamiLos
M.D4
referred
steroid-d#{231}pendent
wheezes throughout both lung fields. A theophylline level was 17.5 g/ml and an a-antitrypsin level was 285 mg/dl (normal, 159 to 251 mg/dl). Results ofarterial blood gas analysis and pulmonary function tests are shown in ‘liable 3 and Figure 1; a pressure-volume curve is shown in Figure 2. A chest xray film exhibited evidence of air trapping and slightly increased
L ..
E of obstructive
R
adulthood
that
S
be confused with severe asthma. The following involves a 24-year-old woman with generalized
bron-
ronchomalacia pulmonary
may
woman,
A 24-year.old
cushingoid
for treatment of presumed asthma, was found to have generalized bronchomalacia. The diagnosis was based on an abnormal collapsibility of the bronchi on bronchoscopic examination and a lack of bronchial reversibility with aggressive bronchodilator therapy. (Chest 1990; 97:489-91)
A 24-year-old
severe
REPORT
CASE
5 McAdams
1.29(40)
3.24(91)
morphologic
Mol Pathol 1980; 33:90-103
Exp
Proudfoot
ofnitrogen-inhalation
is one of many causes disease in both infancy and
case
the National Jewish Center for Immunology and Respiratory Medicine, Denver. tFellow, Allergy-Immuno1og Fitzsimons Army Medical Center, Aurora, Co. jAssistant Professor of Medicine, University of Colorado School of Medicine; StaffPhysician, National Jewish Center for Immunology and Respiratory Medicine. The opinions or assertions contained herein are the private views ofthe authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of
PATIENT
PREDICTED 8
F1 L O Wc 0
5Fmm
Defense.
12
N D -8
-12
Ficua
1
VOLUME (LITERS)
.
Flow-volume
loop
obtained
at the
time
of admission
to
NJC.
CHEST
I 97
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1990 American College of Chest Physicians
I
2
I
FEBRUARY,
1990
489
Table
2-Pulmonary Admission
Measurement FEy,,
(%
L
*PFF5
Table
seven
days
ofIV
3-Pulmonary
1985)
Discharge
(1 1 Feb
1985)*
Prebronchodilator
Postbronchodilator
0.93
(31)
0.93
(31)
0.84
(26)
0.85
(26)
2.88
(72)
2.67
(67)
2.32
(53)
2.40
(62)
methylprednisolone,
IV aminophylline,
Test and Arterial
Function
Blood
Measurement
and inhaled
IV ampicillin,
Gas
Results
Analysis
Admission
TLC,
1985
Postbronchodilator
pred)
after
(6 Feb
February
Prebronchodilator
L (% pred)
FVC,
Test Results,
Function
3-agonists.
During
the Hospitalization
at NJC in May
PFTs
PFTs
Prebronchodilator
Postbronchodilator
1987
10 Days
Later*
Postbronchodilator
Lt
7.90
(158)
7.15
(143)
7.62
(152)
TGV, Lt
6.05
(224)
5.15
(191)
5.52
(204)
RV, Lt
4.33
(373)
3.40
(293)
4.03
(346)
2.64
(69)
2.93
(76)
3.11
(81)
0.66
(19)
0.66
(19)
0.76
(22)
FVC,
Lt
FEy,
Lt
%FEV/FVC
24
Rawt
12.11
SGawt
23 (853)
0.01
Dsbt Dsb/VAt
6.39
(105)
pH
7.41 mm
Hg
mm
Sa02,
Hg
in Denver,
34-38
mm
53 (normal
in Denver,
65-75
mm
function
nebulization PFTs
were
done 1,584
tValues
testing
(961)
0.01
(5)
Hg) Hg)
10 days
after
a pretreatment
in parentheses,
CT scan
chest
biopsy
study
pulmonary
but
(Fig
3) was
otherwise
methylprednisolone
triamcinolone 0.5
ml
(125 acetonide
albuterol
0.5%
complete
collapsibility
complete
collapsibility
No
study airways
mg
q 6 h),
(4 puffs by
qid),
of the of the
collapsibility
by
a panel
bronchi
were
passive
on
severe,
diffuse
expiration,
05%
(0.5
theophylline
Arterial
with
blood
fifth-generation
bronchi
and
bronchi.
There
gas
ml)
with
levels
values
20
mg
in the were
cromolyn
high
by
teens.
obtained
on
These room
air
third-generation
and
more
passive
expiration
techniques
and
not
a marked
a tapering Over
the
therapy
of
ensuing
except
improve
the
reduction
steroid
patient’s
in her
therapy
20 months
for
necessitated
symptoms,
bronchodilator
without
but therapy
a worsening
of
her
severely
brief by
disabled
the
patient
periodic upper
by her
bursts
has
been
(three
to
respiratory
pulmonary
off prednisone four
infections.
times
She
per
remains
condition.
was DISCUSSION
proximal
Collapse with
did
tolerate
symptoms.
year)
nearly
apparatus
did
and
this
including
fourth-generation
ofthe
of
of emphy-
present
revealed
she
bronchi.
Treatment
albuterol
and
nebulization.
breathing
An open
no evidence
results with
A thin-section
as normal
demonstrating
obliterans. the
normal. ofbronchiectasis.
interpreted
pathologists,
of
no abnormal
with
no evidence
Bronchoscopic
collapsibility
was
showed
or bronchiolitis
specimen.
qid),
% predicted.
markings
ofthe
of IV
(2 puffs
m).
peribronchial
sema
after
q 4 h, ipratropium
(altitude,
lung
13.60
(10)
90
*Pjlmony
four
36 (normal
%
(863)
0.02
(95)
Po2,
12.26
(5)
30.57
Pco,,
24
a resistor
passive
of the
bronchi
expiration,’3
should
and
its
normally
presence
not occur
in this
patient
during suggests
,;L P R
E C T
;
I 50
/
100
T L C
,. Patient
\c:A
\
baseline
g* I
0 -20
#{149}
0
#{149}
I
20
Predicted
range
2. Pressure
volume
curve
,
I
#{149}
40
I 60
at the
time
80
of admission
FIGURE
.
‘
“C.
H20)
obtained
.C
‘‘,..
t
490
...
?o
,.,
50
(cm FIGURE
‘ ‘r”:ir’-’
b
PRESSURE
to NJC.
‘%._
b:1,
.:
E
D
;
‘*. ‘
3.
magnification
.
,
. ‘
‘I .
-
,, .
&C #{163}C’
‘-p
1.1
I
‘, ‘4
C-
‘1N
#{149}
..
..-\
md$
Open
(x
lung 170).
biopsy
specimen
Distal Airway
Downloaded from chestjournal.chestpubs.org by guest on July 10, 2011 © 1990 American College of Chest Physicians
obtained
Bronchomalacia
at NJC
(Lavins,
original
Hami!os)
the
diagnosis
diagnosed
of bronchomalacia.
by bronchoscopy, than 50 percent
by more forced such
as
is best
a narrowing
ofthe
lumen Partial
with coughing is pathologic. ofless than 50 percent, may occur during with other forms ofobstructive lung disease
collapse, expiration
bronchial
Bronchomalacia
where
emphysema,
but
does
not
occur
with
manuscript preparation.
and
1 Gandevia
B. The
collapse
in emphysema.
passive
2 Campbell
suggested
4 Nuutinen 63:380-87
J.
5 Campbell
AH,
Previous
by the
abnormal
bronchial
collapse
demonstrated
on bronchoscopy with passive expiration and the exclusion of other diseases such as asthma, emphysema, bmnchiectasis, and bronchiolitis obliterans. The patient also has a clinical history ofchronic bronchitis, but it is not uncommon for bronchomalacia to he associated with chronic bronchitis.6’7 Asthma
improve
is an unlikely
the
testing
on
sema
diagnosis
obstructive
multiple
with
lung biopsy, and the CT scan of the obliterans was ruled out as a potential lung
biopsy,
results
and
of the
bronchiectasis
chest
x-ray
Bronchomalacia
was
film
may
Congenital
be
an
isolated
matic
by age
years.6”
abthty
chest.
function Emphythe open
highly
unlikely of the
chest.
from
or
acquired.4.6.8
Acquired
bronchomalacia
hypothesizes bronchitis
case
of
acquired
except
an
that may
bronchomalacia
with
association
bronchomalacia
occur
when
usually
has
no
obvious
chronic bronchitis. Pohl associated with chronic
irritation
of many
1971;
years’
Keller
Med
bronchial
other
with
of obstructive
possible
causes
presumed
steroid-dependent cannot be demonstrated.
reversibility
lung
disease
asthma
its
Expiratory Bespir
R, Ailgower
M.
air-flow Dis
pattern
Special methods of the central
diseases
in trache-
92:781-91
1965;
of diagnosing
airways.
Chest
60:49-67
6 Johnson
Acquired
JH,
etiology
JJ,
RJ,
TH,
Wilson
collapse,
Feist
RJ.
diagnosis. JS.
Dis
1982;
of
a variant
1963; 57:174-80 Acquired tracheo-
JH.
109:577-80
differential Dunbar
J Respir
Br J Dis Chest
Wilson
1973;
Johnson
JD,
1963;
Tracheobronchial
disease.
Mikita
and
8 Baxter
IF.
Young
Radiology
7 Feist
Eur
bronchomalacia.
respiratory TH,
malacia.
Acquired
Chest
bronchomalacia:
1975;
Tracheomalacia.
68:340-45
Otol Rhinol
Ann
Laryn-
72:1013-23
SJ, Adler P. Scherer lacia) a non-allergic cause 1964; 22:20-25
9 Levin
RA.
Collapsible
trachea
of wheezing
(tracheoma-
in infancy.
Ann
Allergy
Andres
L.
This an
report acute
exposure.
Arteries After Acute to Carbon Monoxlde*
Marius-Nunez,
M.D.
describes
a 46-year-old
myocardial
infarction
The
showed
with Normal
Infarction
Coronary Exposure
man carbon
and
infarction.
The
in
where
monoxide
serum
coronary
one week after admission failed of coronaryobstructive lesions. The ofinterestbecause the clinical presentation
performed dence is myocardilal
who suffered
white after
electrocardiogram
myocardial
enzymes angiogram
to reveal
case
evi-
presented
of
suggestive
absent, the patient was found unconscious and his medical profile was negative for cornnary heart disease risk factors. It is assumed that COHb causes myocardial infarction by severe generalized tissue hypoxia and a direct toxic effect the myocardial snito-
was
infarction
on
chondria.
Contributing
myocardial
factors
oxygenation
are
and an increased
fusion
duration
with a congenital weakness ofconnective tissue or the elastic fiber system. One could speculate that this patient’s bronchomalacia was due to chronic bronchial irritation from her exposure to workplace chemicals as a hairdresser, but there are no real data to substantiate this contention. The prognosis of acquired bronchomalacia in the absence ofan obvious cause is not known. Since this patient presented with presumed steroiddependent asthma and was actually found to have acquired bronchomalacia, this case emphasizes the importance of seeking
in
expiratory tracheobronchial 32:23-31
that
might
an inadequate
thrnmbic
(Chest
C
arbon
monoxide
is considered
also
the
1990;
most
the
Edgewater
Hospital,
nearly
50
per-
percent
97:491-94)
common
intoxication with an average of 10,000 that need medical attention in the United series reported by Zanetti,’ of patients trial
year
decrease
myocardial
tendency.
combines
patients
assistance
1963;
Rev
obstructive
obstructive
gol
LW. Am
Myocardial
adults and can be caused by syphilis, relapsing polychondritis, tracheostomies, endotracheal tubes, and crushing chest trauma.”#{176}’ Chronic bronchitis has been associated with acquired bronchomalacia ofunclear etiology in patients older than age 50 with long smoking histories.” The treatment of bronchomalacia is aimed at preventing tracheobronchial collapse, through either surgery or physiotherapy. Physiotherapy includes pursed-lip breathing, expiration through a resistor apparatus, and possibly the use of continuous positive airway pressure. Surgery is reserved for localized bronchomalacia of the central airways but is not indicated for generalized bronchomalacia ofsmaller airways, which is best treated with physiotherapy. This
his
the
affects
etiology
H,
of gross
Q J
Faulks
treating
and
spirogram
collapse.
3 Herzog
by the open
CT scan
AH,
obronchial
Bronchiolitis
diagnosis
congenital
to
presents during infancy and is Most patients become asympto-
finding.
two
and
either
bronchomalacia
usually
the
defect by pulmonary from 1980 to 1987. the results of the Dsb,
occasions
is implausible
without
for
M.D.,
REFERENCES
reports of bronchomalacia associate this disorder with tracheomalacia; however, tracheomalacia was not observed in this case. The diagnosis of bronchomalacia in this patient was ir’46
Dolen,
WK.
indus-
cases States.’ treated
were found
per In at
uncon-
In KindwaIFs, and Zanetti’s,’ experience, the absolute COHb level did not show an association with the severity of intoxication. However, patients who were unconscious seemed to have a more ominous prognosis secondary to the high incidence of complications or death. Clinical and scious.
experimental 5Fmm
data
the Department
indicate
that
of Medicine,
myocardial Edgewater
isehemia
follow-
Medical
Center,
Chicago.
ACKNOWLEDGMENT:
J.
Waidren,
M.D.
The authors ,
and
G.R.
Cott,
thank M.D.,
E. Fernandez, for their review
M.D., of the
Reprint
iqtsests:
Dr.
Marlus-Nunez,
4523 North
Chicago
Artesian,
&J625 CHEST
I 97 I 2 I FEBRUAR’I
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1990
491
Distal airway bronchomalacia resulting in severe obstructive airway physiology. B J Lavins and D L Hamilos Chest 1990;97; 489-491 DOI 10.1378/chest.97.2.489 This information is current as of July 10, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/97/2/489 Cited Bys This article has been cited by 1 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/97/2/489#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
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