An in vitro model of isolated diaphragmatic muscle fibers was developed to study the effects of theophylline on diaphragmatic contractility. The effects of theophylline on this model were compared for each dose with the effects of the drugs on a "classic" hemidiaphragmatic muscle preparation. Diaphragmatic strips obtained from 20 rats were placed into an open topped channel of a plexiglass tissue chamber and perfused with continuously flowing Krebs solution heated to 37 degrees and bubbled with a 95% O2 and 5% CO2 gas mixture so as to maintain pH, PO2, PCO2 constant (7.4, 100, and 35 mmHg, respectively). Isometric force generated in response to 1 Hz supramaximal electrical stimulation was measured with a highly sensitive photoelectric transducer. Graded doses of aminophylline (15 to 75 mg/L) were administered and their effect assessed on diaphragmatic peak twitch tension. On the single diaphragmatic muscle fibers preparation, theophylline produced a dose dependent increase in peak twitch tension, which, at a concentration of theophylline of 15 mg/L, a therapeutic dose, amounted to 111 +/- 1.5% of control (p less than 0.05). At a concentration of 60 mg/L the increase in peak twitch tension averaged 35 +/- 2.5% of control, (p less than 0.001). On the other hand, theophylline had no effect on the hemidiaphragm preparation until a dose of 250 mg/L. These findings suggest that the effects of theophylline on diaphragmatic contractility are due to a direct action of the drug on the contractile properties of the diaphragmatic fibers and also validate the presented in vitro model as a promising one for future pharmacologic studies on diaphragmatic contractility.

Patients with end-stage pulmonary emphysema are usually proposed for either heart-lung or double-lung transplantation. The single-lung transplantation is reversed for patients with pulmonary fibrosis. Patients with emphysema are thought to be unsuitable for single-lung transplantation because of the ventilation-perfusion imbalance that is supposed to occur, the ventilation being preferentially distributed to the native lung when the perfusion is distributed to the transplanted lung. We now report a preliminary success with single-lung transplantation in two consecutive patients with end-stage pulmonary emphysema. Despite the persistence after transplantation of an obstructive syndrome, the clinical status was good, the blood gases were markedly improved, and ventilation-perfusion imbalance did not occur on lung scans. After discharge from the hospital, the patients could return to an almost normal life. Thus, our data support the feasibility of single-lung transplantation in patients with end-stage pulmonary emphysema, and we consider that single-lung transplantation could be the optimal form of lung transplantation in these patients.

L’oxyde nitrique (NO), élément instable, sécrété par toutes les cellules à partir de NO synthétase (NOS), est très utile pour explorer d'une manière non invasive les fonctions respiratoires. Son effet vasodilatateur pulmonaire permet de l'utiliser en thérapeutique chaque fois que les échanges de O2 sont perturbés.

La nouvelle pneumopathie, appelée pneumonie atypique, revêt dans 20 % de cas l’aspect d’une forme grave (severe acute respiratory syndrome, SARS). C’est parmi ces cas que l’on trouve surtout les 5 % de mortalité. C’est le diagnostic et le traitement tardif qui entraînent ces formes sévères. Il faut donc traiter tôt en se fondant sur le tableau clinique, la notion de contage, l’identification du virus. ribavirine et corticoïdes en sont les éléments principaux.

Les tumeurs primitives de la paroi thoracique sont rares. On peut voir surtout des lipomes, des chondromes, des chondrosarcomes, des sarcomes et des localisations de la maladie de Khaler. Peu de nouveautés, en dehors de l’imagerie, ont marqué ces dernières années.

Lung volume reduction surgery in emphysema has, as an objective, the reduction of dyspnoea and an increase in the exercise tolerance in patients with respiratory insufficiency suffering from diffuse emphysema. In principle the resection of the most diseased areas of emphysema leads to improvement in the mechanical properties of the emphysematous lung and correct pulmonary hyperinflation. The respiratory function benefits both objective and subjective, produced by surgery are real but transitory and inconstant depending in particular on the evolutionary profile of the emphysematous disease. The indications should be further refined and an objective comparison of different surgical techniques has not been achieved. The impact on the quality of life for these patients is unknown.

Tracheobronchial involvement in Crohn's disease is rare, usually associated with symptoms of tracheobronchitis, and typically responds well to steroids. The authors report a case of a 29-yr old patient with Crohn's disease, who presented with dyspnoea, fever, and a productive cough. Computed tomography of the chest revealed extensive nodular tracheobronchial stenosis, that was accompanied by severe mucosal inflammation at bronchoscopy. High-dose oral steroids diminished the mucosal inflammation, but had limited efficacy on the underlying tracheobronchial stenosis. It is speculated that this relative ineffectiveness of steroids may be due to the persistence of the untreated inflammatory process.

BACKGROUND Systemic hypotension may complicate the early postoperative period after lung transplantation. A release of proinflammatory cytokines secondary to lung ischemia/reperfusion injury could be involved in the pathogenesis of this early hemodynamic failure (EHF). STUDY OBJECTIVE To assess prospectively whether the occurrence of EHF is associated with a release of cytokines in the systemic circulation. DESIGN Blood samples were taken daily during the first postoperative week in 26 patients who underwent a double or a single-lung transplantation. These patients were divided into three groups: 7 patients who experienced EHF and subsequently died (EHF group); 15 patients without EHF (control group); and 4 patients without EHF but with an identified sepsis (sepsis group). The serum levels of interleukin (IL)-1beta, tumor necrosis factor-alpha (TNF-alpha), IL-6, and IL-8 were compared among the three groups. RESULTS In the EHF group, the levels of each cytokine peaked at day 1 postoperatively. Cytokine levels at day 1 were significantly higher in the EHF group than in the control group (p<0.0006) or in the sepsis group (p<0.003 except for TNF-alpha). CONCLUSION We conclude that EHF is associated with a massive release of proinflammatory cytokines that could play a determinant role in the pathogenesis of this complication.

BACKGROUND:Minocycline has been identified as a pathogenic agent in drug-induced pneumonia. We report a new case.CASE REPORT:A 38-year-old female asthmatic patient was given minocycline (100 mg/j) for facial acne. She was allergic to penicillin. Other treatments were theophylline, salbutamol and inhaled budesonide. Severe bilateral hypoxemia pneumonia developed with high eosinophil blood counts within a few days of treatment onset. The lung disease regressed with minocycline withdrawal.DISCUSSION:This case is exceptional because the minocycline-induced lung disease continued to progress despite high-dose corticosteroids in this asthmatic patient.

Small airway involvement and progressive severe airflow obstruction are unexpected features in patients with microscopic polyangiitis. We report the case of a patient with microscopic polyangiitis and circulating anti-neutrophil cytoplasmic antibodies (ANCA), who developed pulmonary hyperinflation and airflow obstruction over a 7-yr period. Systemic manifestations of this vasculitis improved under corticosteriods and cyclophosphamid therapy, a treatment that did not influence either the very high level of anti-myeloperoxidase antibodies or the ventilatory impairment. Small airway involvement was suspected on the basis of pathologic small airway lesions and a mild emphysematous pattern on computed tomography (CT) scan, which was out of proportion with the severity of the obstructive lung disease.

Amongst the elements which contributed to the success of the early lung transplants at the beginning of the 1980's we feel that the careful selection of candidates probably played a predominant role. If some of the selection criteria initially described remain somewhat intangible, others have either been eased or have been invalidated. The experience acquired over the last 15 years has enabled to precise the optimal moment to include patients on the waiting list and to refine the choice for the type of surgical procedure according to the underlying disease. This article aims to review the different selection criteria for candidates for transplantation and stresses those which have recently undergone change.

Kaposi's sarcoma (KS) has been reported in 6% of malignancies of solid organ transplant recipients. Most of the observations have been in recipients of renal allografts but, so far, KS has not been described in lung transplantation. We report a case of bronchial KS occurring in a black patient 6 months after single lung-transplantation. Skin lesions were absent and, interestingly, KS lesions were observed solely in the trachea and the native lung. Following reduction of the immunosuppressive regimen a complete remission was obtained 1 year later. Up to the present time, this clinical remission is very encouraging, but close surveillance remains necessary to detect rejection episodes or the reappearance of KS following manipulation of the immunosuppressive therapy.

BACKGROUND: Minocycline has been identified as a pathogenic agent in drug-induced pneumonia. We report a new case.CASE REPORT: A 38-year-old female asthmatic patient was given minocycline (100 mg/j) for facial acne. She was allergic to penicillin. Other treatments were theophylline, salbutamol and inhaled budesonide. Severe bilateral hypoxemia pneumonia developed with high eosinophil blood counts within a few days of treatment onset. The lung disease regressed with minocycline withdrawal.DISCUSSION: This case is exceptional because the minocycline-induced lung disease continued to progress despite high-dose corticosteroids in this asthmatic patient.

Background: For most authors, surgery of emphysema is restricted to resection of large bullae, whereas resection of small bullae or lung volume reduction is generally considered to have poor results.Study objective: To report our experience of lung volume reduction in patients with severe emphysema without large bullae.Patients: Thirteen patients were operated on from 1982 to 1992. Before surgery, they all had severe diffuse emphysema with a dyspnea grade 4 or 5 and mean FEV(1) values of 18+/-5% of predicted. Seven patients had a PaCO2 greater than 42 mm Hg. On radiologic evaluation, they had either small bullae or, most often, areas of destroyed lung.Intervention: The surgical procedure was unilateral in 11 patients and bilateral in 2.Measurements and results: Postoperative assessment included dyspnea grading, FEV(1) measurements, and blood gas analysis followed at 6- to 12-month intervals. There was no perioperative mortality and the morbidity was limited. At 6, 12, 18, 24, and 36 months postoperatively, a symptomatic improvement was observed in 92%, 85%, 54%, 31%, and 31% of the patients, respectively, with FEV(1) increasing by at least 20% in 92%, 46%, 46%, 31%, and 24% of the patients, respectively.Conclusion: Our data show that lung volume reduction may result in symptomatic and spirometric improvement in patients with severe emphysema without large bullae.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication, Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery, Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction, The mechanism is probably related to increased elastic recoil, Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Severe acute asthma remains associated with significant mortality. Medical treatment of acute severe episodes includes oxygentherapy, inhaled or intravenous beta-2-agonists, and high doses of systemic corticosteroids. The benefit of additional treatment with other agents such as nebulized ipratropium bromide, epinephrine and intravenous aminophylline is still not well defined. Mechanical ventilation, which remains necessary in case of life-threatening acute respiratory failure, addresses specific problems: PaCO2 may be allowed to remain elevated and ventilator settings should be chosen that avoid barotrauma under appropriate sedation. The use of inhalation anesthesics, helium or even extracorporeal life support necessitates further study to determine the optimal therapeutic strategy in those particular situations.