U.S. Center for the Alpha One International Registry

AIR Research

Klinik fur Innere Medizin, SP Pneumologie, Intensiv- und Schlafmedizin, Philipps-Universitat Marburg. koehleru@mailer.uni-marburg.de

Long acting beta 2 -agonists belong to the basic therapy of COPD. Especially patients with nocturnal respiratory problems may benefit from this therapy. Long term recording of lung sounds is a new method for quantitative measurements of bronchial obstructions. In combination with polysomnography an evaluation of cardiorespiratory parameters and sleep structure is possible. A total of 10 patients (8 male and 2 female) with moderate COPD (FEV1 58 +/- 11 %) and signs of bronchial obstruction were investigated. The combination of acoustic long term recording and polysomnography was done for 2 or 3 nights without and under therapy (long acting beta 2 -agonist, 50 micro g Salmeterol). In all patients we could find nocturnal bronchial obstruction events. Nocturnal wheezing time was reduced during therapy to 33 +/- 17 % (1. therapy night, n. s.) compared to 49 +/- 30 % without therapy (control night) and to 17 +/- 17 % (2. therapy night, n = 6, p < 0.05) vs. 51 +/- 30 % (control night, n = 6). Sleep efficiency and REM sleep increased (n. s.) under therapy, deep sleep stages NREM III/IV were nearly the same. Acoustic long term monitoring confirms the reduction of nocturnal bronchial obstructions under therapy with beta 2 -agonists. A better sleep quality may be expected from the improvement of the respiratory situation during sleep.

Philipps-Universitat Marburg, 35033 Marburg, Deutschland. grossv@mailer.uni-marburg.de

Patients with bronchial obstructions often have problems to stay asleep at night. The interaction between sleep position and bronchial obstructions has not been investigated until now. A total of 20 patients was included in this study. All patients were recorded one night in our sleep laboratory with a parallel recording of lung sounds using a commercial Pulmotrack 1010 system. The bronchial obstructions were lower in lateral position than in supine position for both tracheal and chest sounds (p = 0,083 and p = 0,036; n.s.). This effect seemed to be especially high in patients with many obstruction episodes. From our results we can conclude that there is a small dependence of bronchial obstructions from sleep position. Further investigations are needed to verify this result.

Klinik fur Innere Medizin-Pneumologie, Klinikum, Philipps-Universitat, Marburg, Deutschland. penzel@mailer.uni-marburg.de

Sleep related breathing disorders have been recognized as a risk factor for cardiovascular disorders. Peripheral arterial tonometry (PAT) allows to monitor vasoconstriction on the finger continuously and non-invasively. We investigated whether the rapid changes of autonomous function can be assessed by PAT. In 21 patients with obstructive sleep apnea and arterial hypertension we recorded PAT in parallel to cardiorespiratory polysomnography and invasive arterial blood pressure. The correlation between periodic PAT attenuations and the total number of apneas (r = 0.656, p < 0.01) and the total number of cortical arousal (r = 0.583, p < 0.01) were significant. The PAT signal cannot substitute blood pressure but allows a good recognition of apneas and subcortical arousal and gives additional information on changes of sympathetic and parasympathetic tone during sleep.

Klinik fur Innere Medizin, SP Pneumologie, Intensiv- und Schlafmedizin, Philipps-Universitat, Baldingerstrasse 1, 35033 Marburg. koehleru@mailer.uni-marburg.de

Bronchial epithelial cell B7-1 and B7-2 mRNA expression after lung transplantation: a role in allograft rejection?

Elssner A, Jaumann F, Wolf WP, Schwaiblmair M, Behr J, Furst H, Reichenspurner H, Briegel J, Niedermeyer J, Vogelmeier C.

Section for Pulmonary Diseases, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Germany. elssner-1@medctr.osu.edu

Obliterative bronchiolitis is commonly interpreted as chronic rejection and involves the bronchial and bronchiolar epithelium. Upregulation of major histocompatibility complex (MHC) II on bronchial epithelial cells (BEC) had been hypothesised to be an important trigger of a bronchus directed rejection response. More recently, the additional expression of the costimulatory molecules B7-1 (CD80) and B7-2 (CD86) on antigen presenting cells were found to play an important role in the activation of T-lymphocytes in transplant rejection. The role of the expression of these molecules by BEC is unclear. BEC obtained by bronchial brushing and bronchoalveolar lavage fluid (BALF) cells from lung transplant recipients were studied and evaluated for messenger ribonucleic acid (mRNA) expression of B7-1 and B7-2 by semi-quantitative reverse transcriptase-polymerase chain reaction. Significantly elevated B7-1/glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA ratios were found in BEC from patients examined during the first 3 months after lung transplantation. Interestingly, in a small group of patients with bronchiolitis obliterans syndrome the B7-1/GAPDH and B7-2/GAPDH ratios were significantly elevated for BEC, whereas no differences were found for the BALF cells. In summary, B7 messenger ribonucleic acid expression by bronchial epithelial cells may play a role in (chronic) lung allograft rejection.

Dept. of Respir. and Crit. Care Med., Philipps-University of Marburg. grossv@mailer.uni-marburg.de

The classic auscultation with stethoscope is the established clinical method for the detection of lung diseases. The interpretation of the sounds depends on the experience of the investigating physician. Therefore, a new computer-based method has been developed to classify breath sounds from digital lung sound recordings. Lung sounds of 11 patients with one-sided pneumonia and bronchial breathing were recorded on both the pneumonia side and on contralateral healthy side simultaneously using two microphones. The spectral power for the 300-600 Hz frequency band was computed for four respiratory cycles and normalized. For each breath, the ratio R between the time-segments (duration = 0.1 s) with the highest inspiratory and highest expiratory flow was calculated and averaged. We found significant differences in R between the pneumonia side (R = 1.4 +/- 1.3) and the healthy side (R = 0.5 +/- 0.5; p = 0.003 Wilcoxon-test) of lung. In 218 healthy volunteers we found R = 0.3 +/- 0.2 as a reference-value. The differences of ratio R (delta R) between the pneumonia side and the healthy side (delta R = 1.0 +/- 0.9) were significantly higher compared to follow-up studies after recovery (delta R = 0.0 +/- 0.1, p = 0.005 Wilcoxon-test). The computer based detection of bronchial breathing can be considered useful as part of a quantitative monitoring of patients at risk to develop pneumonia.

Klinik fur Innere Medizin, SP Pneumologie und Schlafmedizin, Philipps-Universitat, Marburg, Germany. reinke@stud-mailer.uni-marburg.de

Patients with bronchial asthma often have respiratory problems in sleep. The effects of bronchial obstructions while sleeping have been analysed in some studies. For an exact assessment the sleep itself must not be disturbed by the method. The continuous acoustic lung sound detection is such a method. It helps to assess the circadian rhythm during antiobstructive therapy which may lead to a better sleep quality and daytime fitness.

· Intracellular glutathione and bronchoalveolar cells in fibrosing alveolitis: effects of N-acetylcysteine.

Dept of Internal Medicine, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Germany. jbehr@med1.med.uni-muenchen.de

Extracellular glutathione deficiency and exaggerated oxidative stress may contribute to the pathogenesis of fibrosing alveolitis (FA). High-dose N-acetylcysteine (NAC) supplementation partially reverses extracellular glutathione depletion and oxidative damage, but effects on intracellular glutathione are unknown. Intracellular total glutathione (GSHt) and activation of bronchoalveolar lavage cells (BAC) obtained from 18 FA patients (9 males, aged 52+/-2 yrs), before and after 12 weeks of oral NAC (600 mg t.i.d.), were assessed. Eight healthy nonsmokers (2 males, aged 36+/-6 yrs) served as a control group. Intracellular GSHt was decreased in FA (1.57+/-0.20 nmol 1x10(6) BAC(-1) versus 2.78+/-0.43 nmol x 10(6) BAC(-1)). After NAC treatment, the intracellular GSHt content increased (1.57+/-0.20 versus 1.87+/-0.19 nmol x 1 x 10(6) BAC(-1)). The spontaneous oxidative activity of BAC decreased after NAC treatment (2.7+/-0.8 versus 1.0+/-0.2 nmol x 1 x 10(6) BAC(-1) x h(-1)). Interleukin-8 concentration (82.1+/-31.5 versus 80.0+/-22.6 pg x mL bronchoalveolar fluid (BALF), nonsignificant (NS)) and myeloperoxidase activity (1.93+/-0.64 versus 1.55+/-0.47 mU x mL(-1) BALF, NS) did not change significantly, but were found to be inversely correlated to intracellular GSHt. In conclusion, high-dose N-acetylcysteine supplementation increases intracellular glutathione levels slightly. This increase is associated with a mild reduction of oxidative activity but not with a reduction of bronchoalveolar cell activation in these patients.

[Bronchodilators--effective also in negative broncholysis test. Decreased dyspnea decreased in any case]

Klinik fur Innere Medizin, Schwerpunkt Pneumologie, Klinikum der Philipps-Univ., Marburg. Claus.Vogelmeier@med.uni-marburg.de

According to GOLD (Global Initiative for Chronic Obstructive Lung Disease), bronchodilator drugs are indicated for all degrees of severity of COPD. In stage 1, short-acting substances are administered as required; in stage 2, permanent treatment with short- or long-acting bronchodilators is applied. Patients who fail to respond to broncholysis testing can also benefit from such treatment over the long term. Combination treatment with beta 2 sympathomimetics and anticholinergic drugs makes good sense, since additive effects can develop. Since COPD patients often have CAD in addition, consideration must be given to cardiac side effects--in particular in the case of theophylline. The sole life-prolonging treatment for COPD continues to be the long-term administration of oxygen; the only measure capable of stopping progressive deterioration of lung function is cessation of smoking.

Menz G, Buhl R, Gillissen A, Kardos P, Matthys H, Pfister R, Russi EW, Simon HU, Vogelmeier C, Wettengel R, Worth H, Rabe KF.

Klinik fur Innere Medizin, SP Pneumologie und Schlafmedizin, Philipps-Universitat, Marburg, Germany. koehleru@mailer.uni-marburg.de

Patients with obstructive pulmonary disease also have respiratory problems in sleep. The continuous acoustic lung sound detection together with a cardiorespiratory polysomnography allows a synchronous registration of bronchial obstruction as well as vigilance and respiratory parameters in sleep.A total of 20 patients (9 male and 11 female) with known obstructive airway disease and evident diurnal bronchial obstruction were investigated. We did a monitoring in all patients with a nocturnal continuous acoustic lung sound detection together with a cardiorespiratory polysomnography. The mean age was 55 +/- 12 years (range 23 to 74).In all patients acoustic nocturnal bronchial obstructions could be registered. The wheezing-time (time portion of wheezing while sleeping) was 32.1 +/- 27.4 % (mean +/- SD). We could not proof reliable a rhythm of bronchial obstructions. Only 3 patients had increased bronchial obstructions between 3 and 5 AM. The sleep structure was disturbed in 16 of 20 patients with reduced deep sleep, REM sleep and prolonged sleep latency.Knowing about nocturnal bronchial obstructions helps to adapt the antiobstructive therapy. One can expect that an improvement of the respiratory situation also improves sleep quality.

Pneumologie 2001 Aug;55(8):396-400
[Lung and heart-lung transplantation. Guidelines for indications and preoperative diagnosis]

Niedermeyer J, Bewig B, Bickhardt T, Ewert R, Fischer P, Hamm M, Lill J, Meyer FJ, Otterbach I, Vogelmeier C, Wagner F, Wilkens H, Worth H.

· The role of neutrophils in the pathogenesis of obliterative bronchiolitis after lung transplantation.

Department of Internal Medicine, Division of Pulmonary and Critical Care, The Heart and Lung Institute, Ohio State University, Columbus, Ohio, USA.

Obliterative bronchiolitis (OB) represents the most important long-term complication after lung transplantation. Elevated numbers of neutrophils within the airways are a hallmark of OB. It is unclear what causes the recruitment and activation of neutrophils in the airways of patients with OB: the process of chronic rejection itself or infection, which may (especially in latent virus infection) often be overlooked by the currently applied diagnostic procedures. It is well known that besides their physiologic functions in the clearance of invading micro-organisms, activated neutrophils have a remarkable potential to cause damage to lung tissue. This is attributable to their capability to generate reactive oxygen species and to release potentially toxic proteases. It has been shown that the increased numbers of neutrophils in bronchoalveolar lavage fluid of patients with bronchiolitis obliterans syndrome (BOS) after lung transplantation are associated with elevated levels of interleukin-8, the predominant neutrophil chemotactic factor in the lung. As evidence for the impact of neutrophils on the pathogenesis of BOS, there is significant oxidative stress within the airways of patients with BOS. In addition, the milieu within the airways is characterized by an imbalance between neutrophil elastase (NE) and molecules that inhibit NE as a result of an increased burden of NE released by neutrophils. A defective antiprotease shield due to the loss of secretory leukoprotease inhibitor could be demonstrated in BOS. These mechanisms may provide possible targets to develop new therapeutic strategies that either prevent neutrophil sequestration and activation, or inhibit neutrophil products in order to prevent or attenuate airway damage.

[Treatment of bronchial asthma using a new adjustable combination treatment plan: Asthma Control Plan (ATACO)]

Kardos P, Bruggenjurgen B, Martin A, Meyer-Sabellek W, Richter K, Vogelmeier C, Willlich SN, Buhl R.

Gemeinschaftspraxis & Pneumologisch-Allergologisches Zentrum Maingau Krankenhaus, Frankfurt/Main. Peter.Kardos@netsurf.de

The current guideline of the German Respiratory League (Deutsche Atemwegsliga) recommends the synergistic combination therapy with long acting beta 2-agonists and inhalative corticosteroids only for patients suffering from moderate to severe persistent asthma (step 3 and 4 of the asthma severity scale). Now convenient fixed combinations of these substances are available, which could enhance patient's compliance. A large, randomised, parallel-group study in 8000 mild to moderate asthmatics was designed to compare a flexible asthma control plan with the conventional fixed-dose management with respect to quality of life, symptom control and treatment costs. The fixed combination of 6 micrograms Formoterol and 200 micrograms Budesonide per puff in a new dry powder device was applied either due to a novel flexible asthma control plan "ATACO" (group A) or as a standardised conventional dosing regimen (group B) inhaling two puffs b.i.d. In group A (ATACO) patients reduce the run-in dose after four weeks from two puffs b.i.d. to one puff b.i.d. with the option of doubling the dose immediately, if (pre-defined) asthma deterioration occurs. One week later the dose can be either doubled again or reduced due to the actual asthma symptoms of the patient. After run-in, group B patients continue to take two inhalations b.i.d. In this group, asthma exacerbations will be managed as usual by the physician. In contrast, the ATACO group flexible management plan allows the self-medication: an immediate increase in the dose of the fixed combination will lead to both a fast relief of bronchospasm and an automatically higher dosed corticosteroid treatment for the underlying asthmatic inflammation. Conversely, if later asthma symptoms improve, less reliever and controller medication will be needed and used. The immediate treatment of new onset bronchospasm and asthmatic inflammation by the patient himself could maintain at least the same grade of asthma control, as the conventional group B treatment, improve asthma-related quality of life and decrease treatment costs. If the concept works, fixed combinations of long-acting beta 2 agonists and inhalative corticosteroids could have an impact on future asthma guidelines.

Pneumologie 2001 Mar;55(3):159-62
·
[Solid combination of budesonide and formoterol in the treatment of bronchial asthma]

Stadtisches Klinikum St. Georg, Robert-Koch-Klinik, Leipzig. adrian.gillissen@sanktgeorg.de

Transplant Proc 2001 Feb-Mar;33(1-2):1620-1
Incidence and spectrum of infections in lung transplanted patients: comparison of four different immunosuppressive protocols.

Treede H, Reichenspurner H, Meiser BM, Kur F, Furst H, Vogelmeier C, Briegel J, Reichart B.

Influence of four different immunosuppressive protocols on acute and chronic rejection (BOS) after lung transplantation - experiences in 120 patients.

Treede H, Reichenspurner H, Meiser B, Schenk S, Kur F, Furst H, Vogelmeier C, Briegel J, Reichart B.

Pulmonary function and health-related quality of life in a sample of long-term survivors of the acute respiratory distress syndrome.

Schelling G, Stoll C, Vogelmeier C, Hummel T, Behr J, Kapfhammer HP, Rothenhausler HB, Haller M, Durst K, Krauseneck T, Briegel J.

Department of Anesthesiology, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany. gustav.schelling@ana.med.uni-muenchen.de

OBJECTIVE: We performed a follow-up cohort analysis in order to delineate the correlation between pulmonary function (PF) and health-related quality of life (HRQL) in patients after ARDS. DESIGN: Follow-up cohort study. SETTING: A 20-bed ICU of a university teaching hospital. PATIENTS: A cohort of 50 long-term survivors of ARDS. MEASUREMENTS AND RESULTS: Measurements of PF (FVC, FEV1, TLC, D(LCO)) and HRQL (SF-36 Health Status Questionnaire) were made 5.5 years (median value) after discharge from the ICU. Impairments in PF (defined as PF results below 80% of the predicted value) were frequent but generally mild. Twenty patients had a single PF impairment (with limitations in FEV1/FVC ratio in 12 patients being the most common), four patients had two (with D(LCO) and FEV1/FVC ratio impairment the most common) and three patients had pathologic results in three PF tests (FEV1/FVC ratio, TLC and capillary pO2 during exercise in one case, FVC, TLC and capillary pO2 during exercise in the second patient and FVC, TLC and D(LCO) in the third). Compared to normal controls, survivors of ARDS showed impairments in all SF-36 health dimensions (p < 0.001). Patients with multiple (> 1) PF impairments described the lowest HRQL with major limitations in all SF-36 categories (p < 0.037) including physical and mental summary scores (36.5 vs 46.9, p = 0.037 and 31.3 vs 51.4, p = 0.003) when compared to patients with no or only one PF impairment. CONCLUSIONS: Long-term survivors of ARDS have a significant reduction in HRQL and the presence of multiple PF impairments is associated with maximal decrements in HRQL.

[Inhalable corticosteroids in long-term COPD treatment. Opinions of an expert panel]

Gillissen A, Barczok M, Buhl R, Kardos P, Magnussen H, Matthys H, Rabe KF, Rothe T, Russi EW, Schauer J, Schmitz M, Vogelmeier C, Wettengel R, Worth H, Menz G.

Med. Universitatsklinik und Poliklinik II, Bonn. adrian.gillissen@mailer.meb.uni-bonn.de

Transplantation 2000 Jul 27;70(2):362-7
Elevated levels of interleukin-8 and transforming growth factor-beta in bronchoalveolar lavage fluid from patients with bronchiolitis obliterans syndrome: proinflammatory role of bronchial epithelial cells. Munich Lung Transplant Group.

Elssner A, Jaumann F, Dobmann S, Behr J, Schwaiblmair M, Reichenspurner H, Furst H, Briegel J, Vogelmeier C.

Department of Internal Medicine I, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Germany. Elssner@med1.med.uni-muenchen.de

BACKGROUND: Obliterative bronchiolitis (OB), the most important long-term complication after lung transplantation, is thought to be a manifestation of chronic rejection within the airways, with the hallmarks inflammation and fibroproliferation. METHODS: To characterize the inflammatory process in the context of OB we quantified tumor necrosis factor-alpha, interleukin (IL)-8, IL-10, and transforming growth factor (TGF)-beta on the protein and mRNA level in bronchoalveolar lavage fluid samples obtained from patients with bronchiolitis obliterans syndrome (BOS) and without BOS. In addition, bronchial cells sampled by bronchial brushing were analyzed for mRNA expression. RESULTS: In respiratory epithelial lining fluid (ELF) from BOS patients the protein levels of IL-8 (52.4+/-22.2 vs. 4.4+/-0.9 pg/ml ELF, P<0.005) and TGF-beta (5.6+/-1.9 vs. 0.9+/-0.2 ng/ml ELF, P<0.005) were significantly elevated. In addition, bronchoalveolar lavage fluid cells of BOS patients showed increased expression of TGF-beta (1.13+/-0.44 vs. 0.45+/-0.16, optical density [O.D.]/O.D. glyceraldehyde-3-phosphate dehydrogenase [GAPDH], P=0.11) and IL-8 (0.25+/-0.13 vs. 0.09+/-0.03 O.D/O.D. GAPDH, P=0.53) without the differences reaching statistical significance. In contrast, IL-8 mRNA expression of bronchial cells was significantly higher in the BOS group (0.85+/-0.40 vs. 0.22+/-0.10 O.D./O.D. GAPDH, P<0.05). CONCLUSIONS: We assume that IL-8 and TGF-beta may act as key mediators for airway inflammation and fibroproliferation in the pathogenesis of OB, with bronchial epithelial cells serving as a relevant source of IL-8.

Dept of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany.

Obliterative bronchiolitis (OB) is the major long-term complication following lung and heart-lung transplantation. In bronchoalveolar lavage fluid samples obtained from patients suffering from OB, a marked increase in the number of neutrophils and elevated expression of transforming growth factor (TGF)-beta1 had been found. The goal of the study was to evaluate whether TGF-beta1 is capable of interfering with the expression of the secretory leukoprotease inhibitor (SLPI), the dominating defence of the conducting airways against neutrophil elastase (NE). The authors analysed the effects of TGF-beta1 on gene expression and protein release of SLPI by cultured human bronchial epithelial (BEAS-2B) cells. SLPI protein levels in the supernatants were quantified with a specific enzyme-linked immunosorbent assay; SLPI messenger ribonucleic acid (mRNA) levels were measured by reverse transcriptase polymerase chain reaction. Incubation with TGF-beta1 induced a marked decrease in SLPI protein levels (1 ng x mL(-1) TGF-beta1: stimulation index (SI; protein: relation to SLPI protein release of resting cells)=0.56; 10 ng x mL(-1) TGF-beta1: SI=0.48; 50 ng x mL(-1) TGF-beta1: SI=0.37, p<0.01 each) and mRNA expression (1 ng x mL(-1) TGF-beta1: SI (SI mRNA: relation to SLPI mRNA expression of resting cells)=0.46; 10 ng x mL(-1) TGF-beta1: SI=0.31; 50 ng x mL(-1) TGF-beta1: SI=0.18, p<0.01 each) in a dose dependent fashion. Simultaneous incubation of BEAS-2B cells with TGF-beta1 and NE also caused a significant reduction in SLPI synthesis (10 ng x mL(-1) TGF-beta1 + 7.5 U x mL(-1) NE: mRNA SI=0.61, p<0.05; protein SI=0.65, p<0.05; 50 ng x mL(-1) TGF-beta1 + 7.5 U x mL(-1) NE: mRNASI=0.52, p<0.05; protein SI=0.58, p<0.05; 10 ng x mL(-1) TGF-beta1: mRNA SI=0.33, p<0.01; protein SI=0.38, p<0.01). In conclusion, the data suggest that the coincidence of neutrophilia and upregulation of transforming growth factor-beta1 in obliterative bronchiolitis may lead to uninhibited neutrophil elastase activity by downregulation of secretory leukoprotease inhibitor, with the consequence of ongoing injury to the epithelium.

Am J Respir Crit Care Med 2000 Jun;161(6):1968-71
Pulmonary glutathione levels in acute episodes of Farmer's lung.

Department of Internal Medicine I, Division for Pulmonary Diseases, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany. jbehr@med1.med.uni-muenchen.de

Acute episodes of farmer's lung (FL) are associated with activation and migration of neutrophils into the lungs, causing oxidative stress. We conducted a study to evaluate the effect of episodes of FL on antioxidant defense of the lung by glutathione (GSH). A total of 15 patients with symptomatic FL (one female and 14 males, age 42 +/- 1 yr [mean +/- SEM]) underwent a standardized hay exposure test for 1 h and were then monitored through lung function measurements for 6 h, after which bronchoalveolar lavage (BAL) was performed. As a control, 10 asymptomatic farmers (AF) (two males and eight females, age 43 +/- 1 yr) underwent the same diagnostic procedures. At 3 to 6 h after antigen exposure, the lung function of FL patients was significantly impaired (VC: -31 +/- 4%; single-breath diffusing capacity of carbon monoxide [DL(CO)]: -17 +/- 3%; and Pa(O(2)): -14 +/- 2%, all versus baseline, whereas in AF, only minor changes occurred VC: -4 +/- 5%; DL(CO): -9 +/- 3%, and Pa(O(2)): -5 +/- 2%, all versus baseline). The number of neutrophils in bronchoalveolar lavage fluid was increased in FL patients as compared with AF (29 +/- 7 x 10(4)/ml versus 10 +/- 7 x 10(4)/ml, p < 0.05). The concentrations of total and reduced glutathione (GSH(T) and GSH, respectively) in epithelial lining fluid were decreased in FL patients and increased in AF (GSH(T): 292.5 +/- 27.5 microM versus 1, 185.0 +/- 189.9 microM, respectively, p < 0.001; GSH: 256.8 +/- 22.1 microM versus 1,054.5 +/- 172.9 microM, respectively, p < 0.001). These findings suggest that the individual ability to upregulate GSH in the alveolar space in response to an inflammatory stimulus may have implications for the development of symptomatic FL. We conclude that intrapulmonary GSH levels are distinctly different in patients with FL and AF, and that the regulation of GSH may play an important role in the pathogenesis of FL.

Evidence for oxidative stress in bronchiolitis obliterans syndrome after lung and heart-lung transplantation. The Munich Lung Transplant Group.

Department of Internal Medicine I, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Germany.

Bronchiolitis obliterans syndrome (BOS) is the most serious long-term sequel of lung or heart-lung transplantation (H/LTX). Neutrophilia in the lower respiratory tract is a prominent feature of BOS. Because polymorphonuclear leukocytes (PMN) are capable of releasing large quantities of reactive oxygen species, we measured indicators of oxidative stress and glutathione levels representing antioxidant defense in H/LTX patients (HLTX, n=6; double-LTX, n=7; single-LTX, n=9). We analyzed 19 bronchoalveolar lavage (BAL) samples from 13 non-BOS patients (nine female, four male: age 39+/-4 years) and 17 BAL samples from nine BOS patients (five female, four male: age 33+/-2 years). PMN were the predominant BAL cell population in BOS (61.7+/-7.8% vs. 12.3+/-3.4%, P<0.001). Myeloperoxidase activity in the epithelial lining fluid and oxidized methionine residues in BAL-derived proteins were elevated in BOS (8.6+/-1.6 U/ml vs. 2.2+/-0.6 U/ml, P<0.01; and 12.6+/-1.1% vs. 7.7+/-0.8%, P<0.001, respectively). In addition, the concentration of reduced glutathione in epithelial lining fluid was decreased in BOS (162.6+/-20.1 microM vs. 345.8+/-57.1 microM, P<0.01), whereas the proportion of oxidized glutathione was increased (13.9+/-2.0O% vs. 6.7+/-1.2%, P<0.001). PMN, myeloperoxidase, and oxidized methionine residues were inversely correlated, whereas reduced glutathione was positively correlated with forced expiratory volume in 1 sec (P<0.05 to P<0.001). We conclude that excessive oxidative stress and a lack of glutathione are associated with BOS after H/LTX and may play relevant roles in the development of this disorder.

Bronchiolitis obliterans syndrome after (heart-)lung transplantation. Impaired antiprotease defense and increased oxidant activity.

Hirsch J, Elssner A, Mazur G, Maier KL, Bittmann I, Behr J, Schwaiblmair M, Reichenspurner H, Furst H, Briegel J, Vogelmeier C.

Division for Pulmonary Diseases, Department of Internal Medicine I, Institute for Pathology, Ludwig-Maximilians-University of Munich, Germany.

Increased numbers of neutrophils are a common finding in bronchoalveolar lavage fluid (BALF) samples obtained from patients after (heart-)lung transplantation [(H)LTX]. Since proteases and reactive oxygen species secreted by neutrophils are capable of causing substantial damage to the lung tissue if not counterbalanced by the antiprotease and antioxidant screen, we hypothesized that neutrophil products may play a role in the development of obliterative bronchiolitis (OB). A total of 72 BALF samples obtained from 33 patients after (H)LTX were evaluated. Sixteen of these patients were suffering from bronchiolitis obliterans syndrome (BOS) at the time of bronchoalveolar lavage (BAL). As a control, BALF samples from 17 healthy volunteers were analyzed. Anti-neutrophil elastase (NE) activity was quantified by a titration assay. Concentrations of alpha(1)-protease inhibitor (API), secretory leukocyte protease inhibitor (SLPI), NE-API complex, and myeloperoxidase (MPO) were measured by ELISA. Oxidized methionine [Met(O)] was quantified by high-performance liquid chromatography (HPLC). Epithelial lining fluid (ELF) from patients suffering from BOS showed significantly increased neutrophil counts, significantly elevated concentrations of NE-API complex and Met(O), and a significant decrease in the concentration of SLPI. Furthermore, a trend toward an increased NE activity and MPO concentration was observed. These findings suggest that neutrophils may be involved in the development of BOS.

Functional significance of cardiac reinnervation in heart transplant recipients.

Schwaiblmair M, von Scheidt W, Uberfuhr P, Ziegler S, Schwaiger M, Reichart B, Vogelmeier C.

Department of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany. mschwaib@med1.med.unimuenchen.de

BACKGROUND: There is accumulating evidence of structural sympathetic reinnervation after human cardiac transplantation. However, the functional significance of reinnervation in terms of exercise capacity has not been established as yet; we therefore investigated the influence of reinnervation on cardiopulmonary exercise testing. METHODS: After orthotopic heart transplantation 35 patients (mean age, 49.1 +/- 8.4 years) underwent positron emission tomography with scintigraphically measured uptake of C11-hydroxyephedrine (HED), lung function testing, and cardiopulmonary exercise testing. Two groups were defined based on scintigraphic findings, indicating a denervated group (n = 15) with a HED uptake of 5.45%/min and a reinnervated group (n = 20) with a HED uptake of 10.59%/min. RESULTS: The two study groups did not show significant differences with regard to anthropometric data, number of rejection episodes, preoperative hemodynamics, and postoperative lung function data. The reinnervated group had a significant longer time interval from transplantation (1625 +/- 1069 versus 800 +/- 1316 days, p < .05). In transplant recipients with reinnervation, heart rate at maximum exercise (137 +/- 15 versus 120 +/- 20 beats/min, p = .012), peak oxygen uptake (21.0 +/- 4 versus 16.1 +/- 5 mL/min/kg, p = .006), peak oxygen pulse (12.4 +/- 2.9 versus 10.2 +/- 2.7 mL/min/beat, p = .031), and anaerobic threshold (11.2 +/- 1.8 versus 9.5 +/- 2.1 mL/min, p = .046) were significantly increased in comparison to denervated transplant recipients. Additionally, a decreased functional dead space ventilation (0.24 +/- 0.05 versus 0.30 +/- 0.05, p = .004) was observed in the reinnervated group. CONCLUSIONS: Our study results support the hypothesis that partial sympathetic reinnervation after cardiac transplantation is of functional significance. Sympathetic reinnervation enables an increased peak oxygen uptake. This is most probably due to partial restoration of the chronotropic and inotropic competence of the heart as well as an improved oxygen delivery to the exercising muscles and a reduced ventilation-perfusion mismatching.

Lung function and cardiopulmonary exercise performance after heart transplantation: influence of cardiac allograft vasculopathy.

Klinikum Grobhadern, University of Munich, Germany. mschwaib@med1.med.uni-muenchen.de

STUDY OBJECTIVE: The reduced exercise capacity observed in most patients after heart transplantation may be due to treatment with immunosuppressive drugs, deconditioning, cardiac denervation, and graft rejection. Cardiac allograft vasculopathy (CAV) is presently the major factor limiting long-term survival after transplantation. Little information is available with regard to the relationship between CAV and functional impairment in these patients. DESIGN: Prospective. SETTING: A university hospital and a large transplant center. PATIENTS: About 37+/-5 months (range, 2 to 137 months) after orthotopic heart transplantation, 120 patients underwent lung function testing, cardiopulmonary exercise testing, and right and left heart catheterization. Significant CAV was defined as a stenosis > or =70% or severe diffuse obliteration in any of the three main vessels. Group I (n = 28) had a significant CAV; group II (n = 92), without a remarkable CAV, was the control group. MEASUREMENTS AND RESULTS: Overall, the maximum heart rate was 86+/-2% of what was predicted, and the peak oxygen consumption was 18.8+/-0.7 mL/kg/min (64% of that predicted). Groups I and II did not show significant differences with regard to anthropometric data, hemodynamic measurements, or number of rejection episodes. Group I exhibited significant differences in maximum heart rate (120+/-5 vs. 134+/-3 beats/min; p<0.01), work capacity (47+/-5% vs. 59+/-3%; p<0.05), peak oxygen uptake (16+/-1 vs. 20+/-1 mL/min/kg; p<0.01), and functional dead space ventilation (31+/-2 vs. 26+/-1; p<0.01). Pretransplant status, etiology of heart failure, ischemic time, and the number of rejection episodes did not correlate with any exercise parameter. CONCLUSIONS: Following heart transplantation, patients with significant CAV show a diminished exercise capacity, a reduced oxygen uptake, and a ventilation-perfusion mismatch. Thus, CAV may be a major factor limiting exercise capacity in heart-transplant patients.

Thorac Cardiovasc Surg 1999 Jun;47(3):174-8
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Tacrolimus (FK506) as primary immunosuppressant after lung transplantation.

Kur F, Reichenspurner H, Meiser BM, Welz A, Furst H, Muller C, Vogelmeier C, Schwaiblmaier M, Briegel J, Reichart B.

Department of Cardiac Surgery, Klinikum Grosshadern, Ludwig-Maximilian University, Munich, Germany.

BACKGROUND: Our positive experience with tacrolimus (FK 506) in heart transplantation has led to our assessing the use of this medication as a primary immunosuppressant in lung transplantation. 62 of our patients after lung transplantation were included in this study. The first 34 patients were treated with cyclosporine A (CyA), the remaining 28 with tacrolimus. No meaningful differences were found in baseline characteristics. The actuarial one-year survival rate was 70.6% for the CyA group and 92.3% for the tacrolimus group. The number of acute rejection episodes per patient was 1.50 for the CyA group versus 1.18 for the tacrolimus group (p < 0.05). The incidence of infection and their spectrum were comparable in both groups. The most frequently reported adverse events were diabetes mellitus 57% (tacrolimus) vs 23% (CyA), and renal insufficiency (27% vs 15%). Tacrolimus seems to be a more potent immunosuppressant after lung transplantation than CyA; on the other hand, diabetes and nephrotoxicity were diagnosed more frequently using tacrolimus. Although our results are very promising, further follow-up on the incidence of obliterative bronchiolitis is warranted.

Reichenspurner H, Kur F, Treede H, Meiser BM, Deutsch O, Welz A, Vogelmeier C, Schwaiblmair M, Muller C, Furst H, Briegel J, Reichart B.

Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Germany. hcr@hchmed.uni-muenchen.de

BACKGROUND: The successful use of tacrolimus (Tac)-based immunosuppressive therapy in organ transplantation and our own positive experience in heart transplantation led us to investigate regimens including this agent at our center for lung transplantation. METHODS: From 1991 to 1998, 86 patients underwent lung transplants at our center and 78 of them were included in this analysis. The first 34 patients were treated with cyclosporin (CsA), azathioprine (Aza), and rabbit antilymphocyte globulin; the subsequent 30 patients received Tac with Aza, and the most recent 12 patients Tac with mycophenolate mofetil (MMF). In addition, all patients received prednisone. RESULTS: The number of acute rejection episodes per 100 patient days was 1.5, 0.6, and 0.3 for three treatment groups, respectively. Similarly, the incidence of refractory acute rejection per 100 patient days was lower in both Tac groups (0.20, 0.03, and 0, respectively). Freedom from acute rejection was highest in the Tac-MMF group (P=0.0037 vs. Tac/Aza, P=0.0007 vs. CsA/Aza). Freedom from recurrent acute rejection was significantly higher in both Tac groups (P=0.027 Tac/ Aza vs. CsA/Aza and P=0.025 Tac/MMF vs. CsA/Aza). The incidence of infections per 100 patient days was similar (0.8, 0.5, and 0.8) in all three treatment groups, with a similar distribution of fungal, bacterial, and viral infections. Freedom from infection also showed no difference. The survival rate was significantly higher for the Tac population, with actuarial 1- and 3-year survival rates of 93% and 71%, compared with the CsA group (71% and 51%, respectively, P=0.04). Prevalence of renal dysfunction (creatinine >2.0 mg/ dL) was 18%, 13%, and 0% in the 3 treatment groups, respectively. The development of glucose metabolism disorders was lower in the CsA group than in the Tac-Aza group (15% vs. 27%, P<0.05). CONCLUSIONS: Tac-based immunosuppressive therapy results in a lower rate of acute rejection after pulmonary transplantation, with similar infection rates and a slightly higher incidence of new onset diabetes mellitus compared with CsA-based therapy.

· [Established combinations of inhaled corticoids and long-acting beta 2-symphathomimetics for long-term therapy of bronchial asthma. Position of an expert panel study]

Buhl R, Kardos P, Magnussen H, Matthys H, Sauer R, Schauer P, Vogelmeier C, Wettengel R, Worth H, Menz G.

III. Med. Klinik und Poliklinik Universitatsklinikum Mainz. R.Buhl@3-med.klinik.uni-mainz.de

Inhibition of factor XIIIa-mediated incorporation of fibronectin into fibrin by pulmonary surfactant.

Division for Pulmonary Diseases, Department of Internal Medicine I, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, 81377 Munich, Germany. Andreas.Ellsner@med1.med.uni-muenchen.de

Intra-alveolar deposition of exudated plasma proteins is a hallmark of acute and chronic inflammatory lung diseases. In particular, fibrin and fibronectin may provide a primary matrix for fibrotic lung remodeling in the alveolar compartment. The present study was undertaken to explore the effect of two surfactant preparations on the incorporation of fibronectin into fibrin. We observed that surfactant phospholipids are associated with insoluble fibrin, factor XIIIa-cross-linked fibrin, and cross-linked fibrin with incorporated fibronectin. Factor XIIIa-mediated binding of fibronectin to fibrin was noticeably altered in the presence of surfactant. Coincubation with two different commercially available surfactants but not with dipalmitoylphosphatidylcholine alone resulted in a reduction of fibronectin incorporation into fibrin clots by approximately one-third. This effect was not dependent on the calcium concentration. We conclude that 1) factor XIIIa-cross-linked fibrin-fibronectin is able to incorporate surfactant phospholipids in amounts comparable to fibrin clots without fibronectin and 2) the binding of fibronectin to fibrin is partially inhibited in the presence of pulmonary surfactant.

Cardiopulmonary exercise testing before and after lung and heart-lung transplantation.

Schwaiblmair M, Reichenspurner H, Muller C, Briegel J, Furst H, Groh J, Reichart B, Vogelmeier C.

Departments of Internal Medicine, Heart Surgery, and Surgery, and Institute for Anaesthesiology, Klinikum Grosshadern, University of Munich, Munich, Germany. The Munich Lung Transplant Group. mschwaib@med1.uni-muenchen.de

Heart-lung (HLT) and lung transplantation (LT) have been shown to be effective procedures for patients with end-stage cardiopulmonary disorders. As yet, few data exist on the exercise performance of patients before and after thoracic transplantation except with regard to 6-min walk tests. In this article we report cardiopulmonary exercise test results of lung and heart-lung transplant recipients in comparison with their pretransplant values. We studied 103 consecutive recipients of single-lung (n = 46), bilateral lung (n = 32), and heart-lung (n = 25) transplants. Cardiopulmonary exercise testing with a cycle ergometer was performed before and shortly after surgery. Before transplantation, all patients showed severe exercise intolerance and markedly impaired parameters reflecting cardiopulmonary function (e.g., work capacity: 20 +/- 11% predicted; oxygen uptake: 34 +/- 12% predicted; oxygen pulse: 50 +/- 18% predicted; functional dead space ventilation: 57 +/- 10% of minute ventilation; alveolar-arterial oxygen difference during exercise: 79 +/- 15 mm Hg). At 55 +/- 9 d after transplantation, transplant recipients reached maximum oxygen uptakes in the range of 22 to 71% of predicted values; the peak oxygen uptake was increased after transplantation (13.1 +/- 3.4 ml/min/kg versus 10.4 +/- 3.8 ml/min/kg; p < 0.001). Work capacity, oxygen pulse, tidal volume, and peak minute ventilation did not differ in patients following single- or double-lung tranplantation or HLT. Ventilatory factors did not appear to limit exercise capacity in any group. Despite the persistent limitations in aerobic capacity and work rate seen in many of the recipients, cardiopulmonary performance is reasonably well restored shortly after LT and HLT.

Reichenspurner H, Kur F, Treede H, Meiser BM, Welz A, Vogelmeier C, Schwaiblmeier M, Muller C, Furst H, Briegel J, Reichart B.

Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany.

Inhaled nitric oxide (NO) for the treatment of early allograft failure after lung transplantation. Munich Lung Transplant Group.

Kemming GI, Merkel MJ, Schallerer A, Habler OP, Kleen MS, Haller M, Briegel J, Vogelmeier C, Furst H, Reichart B, Zwissler B.

Department of Anesthesiology, Ludwig-Maximilians-Universitat Munchen, Klinikum Grosshadern, Germany.

OBJECTIVE: Inhalation of high concentrations of nitric oxide (NO) has been shown to improve gas exchange and to reduce pulmonary vascular resistance in individuals with ischemia-reperfusion injury following orthotopic lung transplantation. We assessed the cardiopulmonary effects of low doses of NO in early allograft dysfunction following lung transplantation. DESIGN: Prospective clinical dose-response study. SETTING: Anesthesiological intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: 8 patients following a single or double lung transplantation who had a mean pulmonary arterial pressure (PAP) in excess of 4.7 kPa (35 mmHg) or an arterial oxygen tension/fractional inspired oxygen ratio (PaO2/FIO2) of less than 13.3 kPa (100 mmHg). INTERVENTIONS: Gaseous NO was inhaled in increasing concentrations (1, 4 and 8 parts per million, each for 15 min) via a Siemens Servo 300 ventilator. MEASUREMENTS AND RESULTS: Cardiorespiratory parameters were assessed at baseline, after each concentration of NO, and 15 min after withdrawal of the agent [statistics: median (25th/75th percentiles: Q1/Q3), rANOVA, Dunnett's test, p < 0.05]. Inhaled NO resulted in a significant, reversible, dose-dependent, selective reduction in PAP from 5.5(5.2/6.0) kPa at control to 5.1(4.7/5.6) kPa at 1 ppm, 4.9(4.3/5.3) kPa at 4 ppm, and to 4.7(4.1/5.1) kPa at 8 ppm. PaO2 increased from 12.7(10.4/17.1) to 19.2(12.4/26.0) kPa at 1 ppm NO, to 23.9(4.67/26.7) kPa at 4 ppm NO and to 24.5(11.9/28.7) kPa at 8 ppm NO. All patients responded to NO inhalation (either with PAP or PaO2), all were subject to long-term inhalation (1-19 days). All were successfully weaned from NO and were discharged from the intensive care unit. CONCLUSION: The present study demonstrates that low-dose inhaled NO may be an effective drug for symptomatic treatment of hypoxemia and/or pulmonary hypertension due to allograft dysfunction subsequent to lung transplantation.

Radiologe 1998 Oct;38(10):816-23
[Virtual and three-dimensional bronchoscopy with spiral and electron beam computed tomography]

Schoepf UJ, Seemann M, Schuhmann D, Bruning RD, Becker C, Schwaiblmair M, Muller C, Knez A, Haubner M, Krapichler C, Gebicke K, Vogelmeier C, Haberl R, Englmeier KH, Reiser MF.

PURPOSE: To compare spiral computed tomography (CT) and electron-beam CT (EBT) for 3D and virtual CT-bronchoscopy. MATERIALS AND METHODS: 17 patients with various disorders of the tracheobronchial system were examined using fiberoptic bronchoscopy, spiral CT and EBT. 3D images were reconstructed from CT data sets using automated segmentation based on volume-growing methods. Surface-rendered, volume-rendered, and hybrid reconstructions were visualized in real time using a data helmet. RESULTS: All data sets could be processed to high-quality three-dimensional (3D) and virtual reconstructions. The reduction of motion artifacts due to shorter scan times made EBT data sets better suited for automated segmentation and less susceptible to motion artifacts. 3D and virtual reconstructions did not increase the diagnostic sensitivity of CT compared to axial reconstructions alone. CONCLUSIONS: Shorter scan times of CT imaging yield higher-quality 3D and virtual reconstructions. Modern reconstruction techniques are valuable visualization tools for select indications and are the prerequisite for future developments in computer-aided medicine.

Eur J Med Res 1998 Nov 17;3(11):527-32
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Relations between cardiopulmonary exercise testing and quantitative high-resolution computed tomography associated in patients with alpha-1-antitrypsin deficiency.

Medizinische Klinik I, Klinikum Grosshadern, Ludwig-Maximilians-Universitat Munchen, Marchioninistr. 15, D-81377 Munich, Germany. mschweib@med1.med.uni-muenchen.de

High-resolution computed tomography (HRCT) can be used to diagnose and quantify emphysema noninvasively, as significant correlations have been found between the histological grade on resected lung specimens and quantified (q) computed tomography (CT). In this study, we performed thin section qHRCT in patients with severe hereditary alpha-1-antitrypsin (AAT) deficiency. AAT deficiency is the most common genetic cause of emphysema in adults, and exercise intolerance is the most disabling, distressing consequence of emphysema for the majority of patients. qHRCT was used to quantify precisely the alterations in the lung parenchyma due to pulmonary emphysema. Up until now, the important relationship between the severity of emphysema and the reduced exercise capacity has received little attention. Therefore the purpose of the study was to investigate the relationship between emphysema as displayed by qHRCT and cardiopulmonary exercise testing (CPX) in patients with severe cardiopulmonary impairment. - qHRCT was performed in 21 patients with homozygous AAT deficiency. CT scans were obtained at three spirometrically standardized levels at the carina and (5 cm above and below the carina). The mean lung density at 50% of vital capacity and a quantitative histogram analysis of the frequencies of CT values were determined. All patients underwent symptom-limited CPX to analyse simultaneously cardiovascular and ventilatory systems responses. - In all patients, qualitative CT assessment demonstrated panlobular emphysema with large and extensive areas of uniform low attenuation, characteristically with a lower-lobe distribution. Mean CT density values of the patients (-845 +/- 6.9 (mean +/- SEM)) were significantly correlated with work capacity (r = 0.55, p <0.01), oxygen-pulse (r = 0.54, p <0.01) and functional dead space ventilation (r = -0.54, p <0.01). Moreover, severe emphysema index (CT values below a threshold value of 950 HU) correlated positively with functional dead space ventilation (r = 0.60, p <0.01) and alveolar-arterial oxygen difference (r = 0.70, p <0.001). - These results clearly demonstrate that CPX parameters, indicating a disturbed pulmonary gas exchange and a ventilation-perfusion-mismatch during exercise, are significantly related to the extent of lung emphysema.

Drugs Aging 1998 Jun;12(6):429-40
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Alpha 1-antitrypsin. Hope on the horizon for emphysema sufferers?

Department of Internal Medicine, Klinikum Grosshadern, University of Munich, Germany.

Alpha 1-Antitrypsin (alpha 1AT) deficiency is the most common genetic cause of liver disease in children and emphysema in adults. Therapy for pulmonary disease attributable to alpha 1AT deficiency includes alpha 1AT augmentation therapy along with supportive measures. The alpha 1AT preparation that is currently used for therapy is derived from fractionated plasma. The results of clinical trials suggest that augmentation therapy with alpha 1AT slows the progression of emphysema and causes few adverse events. Patients with plasma levels of alpha 1AT that are < 11 mumol/L and who have airway obstruction should be considered for augmentation therapy. Novel approaches include the administration of aerosolised alpha 1AT, recombinant alpha 1AT, gene therapy and synthetic elastase inhibitors.

Biochemical and cellular composition of alveolar epithelial lining fluid in anesthetized healthy lambs.

Ludwig-Maximilians-University, Institute for Surgical Research, Munich, Germany.

Pulmonary toxicity of inhaled materials is often evaluated by (repetitive) assessment of the composition of bronchoalveolar lavage (BAL) fluid or of epithelial lining fluid (ELF) in sheep and lambs. Knowledge of the typical constituents of these fluids obtained from healthy animals is essential for identification of pathologic changes. Few studies have dealt with normal constituents of BAL fluid or ELF in sheep and lamb. The comparability of these studies, however, is limited for reasons concerning the choice of model and BAL technique. The biochemical and cellular composition of alveolar ELF obtained by a standardized BAL procedure was examined in 15 pento-barbital anesthetized 4 months old Merino lambs unexposed to inhaled substances. ELF volume was calculated by using the urea dilution method. We found 20.3 x 10(5) leucocytes per ml ELF, 87.5% of which were alveolar macrophages. Basophils and neutrophils were practically absent while 5% of the counted cells were lymphocytes. 76% of recovered cells were viable. The ELF contained 7 mg/ml total protein; enzyme activities of LDH and AP were 1692 U/l and 145 U/l, respectively.

Int Arch Occup Environ Health 1997;70(6):419-23
Occupational asthma in hairdressers: results of inhalation tests with bleaching powder.

STUDY OBJECTIVE: To analyze the extent to which the clinical diagnosis of bleach-induced asthma can be confirmed by laboratory tests and to determine the role of work-related exposure to bleaching powder in a group of hairdressers with respiratory complaints. METHODS: The study population consisted of 55 female hairdressers who had regular contact with various hair products and a clinical history of job-related rhinitic and/or asthmatic symptoms. We divided the individuals into two groups: group I, with asthmatic symptoms (n = 38), and group II, without asthmatic symptoms (control group, n = 17). All subjects underwent immunological, pulmonary-function, and nonspecific bronchial provocation tests, and 46 study participants were subjected to a standardized bleaching-powder test in a designated chamber. RESULTS: There were 13 positive responses to bleaching powder in the skin test, and 32 individuals showed positive bronchial responsiveness to acetylcholine; positive responses to the challenge with bleaching powder occurred in 9 women (22% of those tested). None of the women in group II reacted to bleaching powder. There was no significant difference between persons with a positive or a negative bronchial provocation test with regard to the evaluated parameters. CONCLUSIONS: In the diagnostic workup of hairdressers with work-related respiratory symptoms, bleaching powder is one of the products that need to be tested. As not every patient with an asthmatic response to bleaching powder shows a positive response to the acetylcholine challenge test, in doubtful cases a specific exposure test may be recommendable.

Antioxidative and clinical effects of high-dose N-acetylcysteine in fibrosing alveolitis. Adjunctive therapy to maintenance immunosuppression.

Abteilung fur Pneumologie, Klinikum Grosshadern, Ludwig-Maximilians-Universitat Munchen, Germany.

In fibrosing alveolitis (FA), activated phagocytes cause excessive oxidative stress in the lower respiratory tract. Additionally, levels of glutathione, a major antioxidant of the human lung, are markedly reduced. Since N-acetylcysteine (NAC) is a known precursor for glutathione synthesis, we investigated the effect of NAC on redox balance and lung function in FA. Eighteen patients with an established diagnosis of FA were treated with 600 mg NAC three times daily for 12 wk in addition to their latest immunosuppressive therapy. Before and after NAC therapy, pulmonary function tests (PFTs) and bronchoalveolar lavage (BAL) were performed. BAL fluid was analyzed with regard to cell differential, glutathione status, and methionine sulfoxide content of BAL proteins (Met(O)), as an indicator of oxidative stress at the alveolar surface. There was an increase of total glutathione (GSHt = GSH +/- 2 x GSSG: 3.43 +/- 0.30 microM versus 4.20 +/- 0.66 microM, p < 0.05) and of reduced glutathione (GSH: 2.58 +/- 0.24 microM versus 3.42 +/- 0.54 microM, p < 0.005) in native BAL fluid and in the epithelial lining fluid (GSHt: 267.3 +/- 26.0 microM versus 367.1 +/- 36.0 microM, p < 0.005; GSH: 204.5 +/- 20.7 microM versus 302.9 +/- 32.2 microM, p < 0.005). The increase of GSH was accompanied by a decrease of Met(O) (6.83 +/- 0.71% versus 4.60 +/- 0.40%, p < 0.005). PFTs significantly improved during NAC treatment. We conclude that high-dose NAC significantly improved the antioxidant screen of the lungs by elevating GSH levels. Moreover, the decrease of Met(O) levels indicated an antioxidant effect at the alveolar surface. These biochemical changes were accompanied by an improvement of PFTs in patients under maintenance immunosuppression. NAC supplementation should, therefore, be considered as an adjunct therapy for FA.

Expression of inducible nitric oxide synthase and formation of nitric oxide by alveolar macrophages: an interspecies comparison.

Nitric oxide (NO) is suggested to play a role in mediating pulmonary injury. However, interspecies differences appear to exist in the ability of alveolar macrophages (AM) to express the inducible nitric oxide synthase (iNOS) and to generate NO. The purpose of this study was to compare iNOS expression and NO production by rat, hamster, monkey, and human AM using the identical experimental conditions in vitro. As AM donors, CD rats, Syrian golden hamsters, cynomolgus monkeys, and nonsmoking, healthy human volunteers were used. The AM were obtained by bronchoalveolar lavage and stimulated in vitro with various concentrations and combinations of lipopolysaccharide (LPS) and interferon-gamma (IFN-gamma). The oxidation product of NO, nitrite, was measured in the AM supernatant by the Griess reaction. The expression of iNOS in AM was detected using immunocytochemistry and immunoblotting. The expression of iNOS mRNA was assessed by reverse transcriptase-polymerase chain reaction (RT-PCR). Rat AM, stimulated with either LPS or IFN-gamma, produced nitrite in a time- and dose-dependent manner. Combination of LPS and IFN-gamma resulted in a significantly enhanced nitrite formation. However, none of the treatments was able to induce hamster, monkey, or human AM to release measurable amounts of nitrite. Whereas expression of iNOS protein was only detected in stimulated rat AM, expression of iNOS mRNA was found in unstimulated and stimulated rat AM, slightly in stimulated hamster AM, but not in monkey and human AM. In conclusion, our findings point to distinct regulatory mechanisms of the NO pathway in AM from these four different species.

Eur Respir J 1997 Oct;10(10):2360-5
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Cardiopulmonary exercise testing following hay exposure challenge in farmer's lung.

Dept of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany.

In patients experiencing an acute episode of hypersensitivity pneumonitis (HP), the alveoli and interstitium show a marked inflammation. The effects of this infiltration with effector cells on gas exchange and the cardiopulmonary system are not well characterized, and there are no data regarding cardiopulmonary exercise testing during hypersensitivity pneumonitis. The aim of this study was to gain new insights into the pathophysiology of acute farmer's lung using cardiopulmonary exercise testing. Cardiopulmonary exercise testing was performed in patients who had farmer's lung (n=21) before and 4 h after a standardized exposure with mouldy hay. Farmers who were asymptomatic for this condition (n=15) served as controls. At baseline, patients who had farmer's lung had a decreased breathing reserve and a greater alveolar to arterial oxygen difference. Following exposure, all of these patients developed hypersensitivity pneumonitis. Compared to the asymptomatic farmers, they showed an increase of alveolar to arterial oxygen difference and functional dead space ventilation during exercise and a reduction of the breathing reserve. In addition, 40% of the asymptomatic farmers demonstrated a pathological increase of the alveolar to arterial oxygen difference during exercise following exposure. In conclusion, our data signify that acute hypersensitivity pneumonitis induces significant changes in pulmonary gas exchange during exercise. Cardiopulmonary exercise testing may help to identify individuals with possible subclinical farmer's lung disease.

Universitats-Klinikum Charite, Zentrum fur Innere Medizin, Medizinische Klinik und Poliklinik II, Schumannstr. 20-21, Berlin D-10117, Germany.

The pulmonary function of 88 consecutive leukemic patients who had undergone allogeneic bone marrow transplantation (BMT) was studied beforehand, at 3 months, at 6 months, and annually thereafter until 5 years after grafting. The parameters for function which are indicative for obstructive and restrictive lung disease deteriorated in all patient groups during the first 3 to 6 months after BMT but partially recovered within one year. Long-term decline in lung function was similar in all patient groups, and neither the onset nor the magnitude of pulmonary dysfunction was related to the occurrence of pulmonary impairment within 6 months after grafting. Multivariate analysis was then employed to assess predictors for long-term pulmonary disease. Despite the obvious effect of chronic graft versus host disease on the course of lung function, it was in itself not a significant predictor of long-term pulmonary outcome. Rather, the conditioning regimen turned out to be indicative; compared with busulfan, fractionated total body irradiation was demonstrated to be clearly superior with a lower incidence of both restrictive and obstructive long-term lung impairment. Our data indicate a previously unknown long-term side effect of busulfan conditioning.

Comparative loss of activity of recombinant secretory leukoprotease inhibitor and alpha 1-protease inhibitor caused by different forms of oxidative stress.

Pneumologische Abteilung, Medizinische Klinik I, Klinikum Grosshadern, University of Munich, Germany.

Secretory leukoprotease inhibitor (SLPI) and alpha 1-protease inhibitor (alpha 1-PI) are powerful antiproteases currently under investigation for their potential to protect the lung from neutrophil elastase (NE). The aim of this study was to determine whether the recombinant form of SLPI (rSLPI) and alpha 1-PI show different grades of loss of inhibitory activity when exposed to reactive oxygen metabolites. We incubated rSLPI and alpha 1-PI with N-chlorosuccinimide (NCS), chloramines, activated polymorphonuclear leucocytes (PMNs) and activated alveolar macrophages (AMs). Under all conditions evaluated, both antiproteases were partially inactivated. The resulting anti-NE activity of rSLPI was not significantly different from that of alpha 1-PI after exposure to NCS (p > 0.5), chloramines (p > 0.6), activated PMNs (p > 0.07) and activated AMs (p > 0.9). In conclusion, recombinant secretory leukoprotease inhibitor and alpha 1-protease inhibitor lose antineutrophil elastase activity to a similar extent when exposed to conditions that may be present in inflammatory lung disorders.

Am J Respir Crit Care Med 1997 Feb;155(2):536-41
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The intrapulmonary half-life and safety of aerosolized alpha1-protease inhibitor in normal volunteers.

Pneumologische Abteilung, Medizinische Klinik und Poliklinik I, Klinikum Grosshadern, University of Munich, Germany.

Aerosol delivery of alpha1-protease-inhibitor (alpha1-PI) has the potential for reducing the amount of alpha1-PI needed to treat persons who are severely alpha1-PI-deficient, thereby decreasing the high cost of treatment and making alpha1-PI available to treat many alpha1-PI-deficient persons who do not now have access to that product. Aerosolized alpha1-PI may also be useful in cystic fibrosis. The goal of our study was to evaluate the duration of action of aerosolized alpha1-PI and possible side effects in normal volunteers. Twenty-nine volunteers underwent bronchoalveolar lavage (BAL) and 3 to 7 d later inhaled 200 mg of alpha1-PI. Subjects were subsequently assigned to one of five groups; a second BAL was performed 0.5, 6, 12, 24, or 36 h after the aerosol, respectively. The BAL fluid samples were analyzed for alpha1-PI concentrations, anti-neutrophil elastase (NE) activity, cell count and differential, alpha1-PI-NE complex level, and uptake of alpha1-PI by alveolar macrophages. Overall we observed no substantial side effects. The one-time alpha1-PI aerosol induced a significant increase of alpha1-PI concentrations as well as anti-NE activity. Even in the BAL fluid samples obtained 36 h after aerosol administration alpha1-PI concentrations and anti-NE activity were about double baseline values. The half-time in the lungs for alpha1-PI concentrations and anti-NE activity were about double baseline values. The half-time in the lungs for alpha1-PI was 69.2 h and for anti-NE activity was 53.2 h, respectively. We conclude from our data in normal volunteers that inhalation of aerosolized alpha1-PI may be a safe, effective, and conveniently administered therapy for persons with severe alpha1-PI deficiency; this mode of administration warrants further study.

Respiration 1997;64(1):10-5
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Long-term augmentation therapy in twenty patients with severe alpha-1-antitrypsin deficiency--three-year follow-up.

Abeitilung fur Pneumologie, Klinikum Grosshadern, Ludwig-Maximilians-Universitt, Munchen, Deutschland.

The purpose of this uncontrolled, prospective study was to evaluate the influence of long-term augmentation therapy with plasma-derived alpha 1-antitrypsin (AAT) on lung function parameters in patients with severe emphysema caused by AAT deficiency. Twenty patients (mean age 48 years) received AAT infusions once weekly for up to 36 months. No adverse effects were observed. At the beginning of the study, mean (+/- SEM) FEV1 was 1.35 +/- 0.12 liters and mean TLCO was 54 +/- 4% of predicted. After 36 months of treatment, mean FEV1 was 1.25 +/- 0.12 liters (p = n.s) and the TLCO was 52 +/- 4% predicted (p = n.s). Similar values were obtained before and after therapy for FVC (2.79 +/- 0.23 vs. 2.82 +/- 0.21 liters), MEF50 (0.72 +/- 0.09 vs. 0.68 +/- 0.08 liters/s), RV (4.60 +/0 0.44 vs 4.45 +/- 0.311) and TLC (7.72 +/- 0.49 vs. 7.38 +/- 0.42 l). The calculated annual loss of FEV1 (35.6 ml/year) was smaller than in historical untreated patients with AAT deficiency.

Chest 1996 Dec;110(6 Suppl):267S-272S
· Oxidant-protease interaction in the lung. Prospects for antioxidant therapy.

Medizinische Klinik II, Zentrum der Inneren Medizin, Johann-Wolfgang-Goethe-Universitat, Frankfurt, Germany.

In inflammatory lung disorders, oxidants and proteases complement each other in their potential to destroy lung parenchyma. It is therefore rational to combine therapeutic strategies aimed at augmenting the antiproteolytic defenses of the lung in diseases such as emphysema with antioxidant strategies. In the healthy lung, the oxidant burden is balanced by the local antioxidant defenses. However, both an increased oxidant burden and/or decreased antioxidant defenses may reverse the physiologic oxidant-antioxidant balance in favor of oxidants, leading to lung injury. This concept points to an obvious therapeutic strategy: augmentation of the antioxidant screen of the lung to prevent oxidant-mediated tissue damage. Studies using reduced glutathione (GSH), the major pulmonary antioxidant, as a model therapeutic agent demonstrated that GSH can be administered directly to the respiratory epithelial surface by aerosol and is fully functional as an antioxidant both in vitro and in vivo. In pulmonary diseases such as idiopathic pulmonary fibrosis or following HIV infection, GSH aerosol therapy not only normalized deficient pretherapy GSH levels in the lung, but was capable of favorably influencing cellular events such as oxidant release by pulmonary inflammatory cells. The same was true for oral antioxidant therapy with N-acetylcysteine, a glutathione precursor. These results suggest that it is possible to use antioxidants to reverse the imbalance between oxidants and antioxidants at the site of oxidant injury to prevent the progressive tissue damage in lung disorders characterized by high oxidant states. Antioxidants, alone and in combination with antiproteases, merit further long-term studies for clinical therapy.

· Use of secretory leukoprotease inhibitor to augment lung antineutrophil elastase activity.

Pneumologische Abteilung, Medizinische Klinik I, Klinikum, Grosshadern, Ludwig-Maximilians-Universitat Munchen, Germany.

Physiologically, secretory leukoprotease inhibitor (SLPI) is the major antiprotease of the epithelium of the upper respiratory tract providing protection against neutrophil elastase (NE). The recombinant form of SLPI (rSLPI) has several advantages compared with alpha 1-antitrypsin that make it interesting as potential therapy. In vitro, rSLPI proves to be an excellent inhibitor of NE. When administered as an aerosol in vitro and in vivo, the structure and function of rSLPI remain intact. Using the aerosol route, the half-life of rSLPI in respiratory epithelial lining fluid is 12 h; thus, giving it twice daily should guarantee satisfactory levels in the lung. Following inhalation, rSLPI moves from the epithelium in an intact form into the interstitium of the lung. Following on from these in vitro and in vivo experiments, a short-term study in patients with cystic fibrosis was performed with aerosolized rSLPI. Promising results relative to NE level reduction and the consequences for the inflammatory process in the bronchi were achieved. rSLPI not only induced an increase of the anti-NE protective screen, but also improved the antioxidant protection by raising glutathione levels in the lung in sheep. rSLPI may therefore provide a unique opportunity for protecting the lung from the damage caused by inflammatory processes by giving a single drug.

Bronchoalveolar lavage for evaluation and management of scleroderma disease of the lung.

Department of Internal Medicine I, Klinikum Grosshadern, University of Munich, Germany.

Fibrosing alveolitis (FA) is a frequent and often fatal complication of systemic sclerosis (SSC). Alveolar inflammation has been recognized as a primary event in the pulmonary manifestation of SSC. To evaluate the significance of the alveolitis in SSC, we performed bronchoalveolar lavage (BAL) and correlated the generated data with changes in lung function over time. Seventy nine SSC patients with pulmonary involvement were followed for 56.8 +/- 3.1 wk (mean +/- SEM) with a repeat lung function test at the end of the follow-up period. During follow-up, 38 patients were treated with a systemic immunosuppressive regimen. For evaluation, patients were assigned to two groups according to whether their BAL cell differential was normal (inactive BAL) or abnormal (active BAL: i.e., polymorphonuclear leukocytes > 5% and/or lymphocytes > 15%). Active BAL was associated with more severe lung function impairment than was inactive BAL, and patients with active BAL deteriorated during follow-up if untreated. In contrast, treated patients with active BAL stabilized or improved. In summary, active alveolitis as characterized by BAL is associated with progressive pulmonary disease in SSC patients, and a significant positive effect of immunosuppressive therapy on the course of pulmonary disease was observed in patients with active BAL.

Inhalation of prostacyclin (PGI2) for 8 hours does not produce signs of acute pulmonary toxicity in healthy lambs.

Habler O, Kleen M, Zwissler B, Pusch R, Welte M, Vogelmeier C, Kempter B, Krombach F, Messmer K.

Institute for Surgical Research, Ludwig-Maximilians-University, Munich, Germany.

OBJECTIVE: To study the potential side effects and toxicity of inhaling prostacyclin (PGI2) aerosol for 8 h. DESIGN: In a prospective, randomized study 14 healthy lambs received either PGI2 (n = 7) or 0.9% NaCl (n = 7) as an aerosol for 8 h. SETTING: Institute for Surgical Research of the Ludwig-Maximilians-University of Munich. INTERVENTIONS: All animals were studied under general anesthesia in a prone position. They were first intubated endotracheally and later tracheotomized. PGI2 solution (median dose 28 ng/kg per min) or 0.9% NaCl was administered with a jet nebulizer (delivery rate 4-10 ml/h; mass median diameter of aerosol particles 3.1 microns). Bronchoalveolar lavage was performed before and after the inhalation period to collect epithelial lining fluid of alveoli. MEASUREMENTS AND RESULTS: Hemodynamic and respiratory parameters, systemic resorption (plasma levels of 6-keto-prostaglandin-F 1 alpha), in vitro bleeding time, collagen-induced platelet aggregation and global biochemical and cellular composition of the epithelial lining fluid were examined in order to assess the side effects and signs of acute pulmonary toxicity induced by inhaled PGI2. No statistically significant differences were found between the PGI2 and the control groups for any of the parameters examined. CONCLUSION: Inhalation of PGI2 (28 ng/kg per min) over a period of 8 h in healthy lambs does not produce major side effects or acute pulmonary toxicity.

Characterization and quantification of alveolar monocyte-like cells in human chronic inflammatory lung disease.

Institute for Surgical Research, Klinikum Grosshadern, University of Munich, Germany.

This flow cytometric study was designed to identify, characterize and quantify alveolar monocyte-like cells in healthy volunteers and in patients with chronic inflammatory lung disease. Cells were obtained by bronchoalveolar lavage (BAL) from 19 patients with sarcoidosis, 29 with idiopathic pulmonary fibrosis, 10 with extrinsic allergic alveolitis, 19 with collagen vascular disease, and from 10 healthy volunteers. By taking advantage of the distinct electro-optical features of alveolar macrophages (AMs) and monocyte-like cells, the numbers of alveolar monocyte-like cells were counted, the cell dimensions calculated, and the densities of antigens on the surface of alveolar monocyte-like cells and AMs were compared. By using a panel of monoclonal antibodies detecting CD11b, CD14, CD16, and human leucocyte antigen-DR (HLA-DR), the immunophenotypes of these cells were selectively characterized. In the BAL fluid of patients with chronic inflammatory lung disease, significantly increased numbers of alveolar monocyte-like cells were detected that exhibited an immunophenotype intermediate between blood monocytes and mature AMs. Positive correlations were found between numbers of monocyte-like cells and expression of the monocyte-associated surface antigens CD11b and CD14 on total AMs; in contrast, an inverse relationship existed between monocyte numbers and expression of the macrophage-associated surface antigens CD16 and HLA-DR. When the patients were assigned to two groups according to the percentage of BAL monocyte-like cells being lower or higher than 13% (= mean value of the controls +2SD), it could be demonstrated that a high percentage of BAL monocyte-like cells was associated with significantly reduced lung function parameters. In summary, our flow cytometric data strongly support the view that considerable numbers of blood monocytes are recruited to the bronchoalveolar space in patients with chronic inflammatory lung disease.

Transplantation 1996 Apr 15;61(7):1117-9
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Sarcoidosis recurrence following lung transplantation.

Muller C, Briegel J, Haller M, Vogelmeier C, Bittman I, Welz A, Furst H, Dienemann H.

Sarcoidosis is a rare indication for lung transplantation. In this article, our experiences with recurring sarcoidosis following lung transplantation are described. Literature concerning recurrence of the disease in kidney, liver, heart and lung transmission of sarcoidosis via transplanted organs are discussed.