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We performed a prospective study of 6MWD compared to other functional assessments in a large group of unselected sarcoidosis patients followed up in one clinic. 6MWD was < 400 m in 73 patients (51%). This impairment in 6MWD was associated with several factors, including pulmonary function and patient perception of level of dyspnea. The best predictors of 6MWD were SGRQ, vital capacity, and initial oxygen saturation.
Traditionally, the effect of sarcoidosis on pulmonary status is assessed by pulmonary function studies and chest roentgenogram. In particular, changes in FVC have been used to assess extent and progression of disease and response to therapy. However, it has been suggested that other testing should also be used to better understand the impact of sarcoidosis on the pulmonary status of the patient. In this study, we did not measure the diffusion capacity, which has provided more information regarding exercise capacity than that obtained by the lung volumes alone.
Two hundred ninety sarcoidosis patients were seen in the University of Cincinnati Interstitial Lung Disease and Sarcoidosis Clinic during the 6-week period commencing June 2005. Of these, 142 patients (49%) completed all aspects of the study. All but six patients had a confirmation of the diagnosis of sarcoidosis from the lung and/or elsewhere. In the remaining six patients, the clinical presentation and BAL findings were consistent with sarcoidosis. The most common reasons for not participating were inability to walk or insufficient time to complete the study. Figure 1 is a histogram of the 6MWD. Median 6MWD for the group was 396 m. Seventy-three patients (51%) completed a 6MWD < 400 m; of these, 32 patients (22%) walked < 300 m.
Table 1 summarizes the characteristics of the patients studied as well as the difference in 6MWD. There was no correlation between age and 6MWD (p — 0.014, p > 0.10). Female and white patients had shorter 6MWDs. The majority of the patients in the study were receiving systemic therapy, which reflects the bias of the tertiary care clinic. Patients could be receiving systemic therapy for nonpulmo-nary reasons, including ocular, cutaneous, hepatic, and neurologic diseases. Patients with limited ambulation from neurologic disease did not participate in the study. Patients receiving therapy had shorted 6MWDs (p < 0.05). The majority of patients had multiorgan disease, with 39 patients (27%) having only pulmonary disease. The presence of pulmonary disease alone was not associated with a significant difference in 6MWD. Cardiac evaluation with echocardiography and/or right-heart catheterization were performed in 49 patients (35%) within 2 years of the 6-min walk test. We documented left ventricular cardiac dysfunction in 10 patients. Fourteen patients had documented pulmonary arterial hypertension with no evidence of left ventricular dysfunction. Only pulmonary arterial hypertension was associated with a significantly shorter 6MWD (p < 0.0001). Of the 28 patients undergoing right-heart catheterization, there was no correlation between either the pulmonary artery systolic pressure or pulmonary artery mean pressure and the 6MWD.
The 6-min walk test has been used to assess the functional status of patients with a wide variety of pulmonary diseases, including pulmonary hypertension, COPD, and idiopathic pulmonary fibrosis. Because it has been shown to predict mortality for several end-stage lung diseases, it is often assessed in patients being considered for lung transplantation. The 6-min walk has largely replaced standardized exercise testing in the assessment of lung disease for many reasons, including its low cost, simplicity, ease of performance, reproducibility, and ability to perform in clinic with minimal equipment. Results from several multicenter trials demonstrate that the test results are comparable across multiple sites.
In sarcoidosis, extrathoracic manifestations of the disease could affect the 6-min walk distance (6MWD). Several studies have demonstrated a discrepancy between pulmonary function and the perception of dyspnea in patients with sarcoidosis. Nevertheless, the use of the 6-min walk may provide a better understanding of the pulmonary status of patients with sarcoidosis. Martin et al emphasized the need for better testing of overall lung function in sarcoidosis. Nowadays My Canadian Pharmacy my-medstore-canada gives people an opportunity to treat various diseases inclusively of sarcoidosis.
The use of aminophylline has been associated with significant cardiac and systemic toxicity, including sudden death, and most morbid events have been associated with theophylline levels in excess of 2μg/ml. The dysrhythmic effects of combined aminophylline-epinephrine have not been formally demonstrated, but each drug has been shown to increase heart rate, inotropia, and dysrhythmogenicity, and to initially lower the threshold for ventricular fibrillation in anesthetized dogs. One investigator demonstrated elevated catecholamine (norepinephrine and epinephrine) levels in response to intravenous aminophylline infusion and was also able to produce ventricular dysrhythmias in healthy subjects by similar administration.
Recent clinical investigations have examined the prolonged electrocardiographic recordings of patients with chronic obstructive pulmonary disease (COPD). Although important atrial and ventricular dysrhythmias were demonstrated in a majority of these patients, the relationship of these rhythm disturbances to concomitant drug therapy, particularly theophylline compounds or sympathomimetics, was not evaluated. Further, no relationship was shown between the type and frequency of dysrhythmias and associated hypoxemia or acidosis, and major pathophysiologic differences between these individuals and those with acute bronchial asthma (mean age, underlying coronary vascular disease, chronic hypoxemia, chronic airway obstruction, etc) render extrapolation of those data inconclusive.
The Student’s t-test was used to compare the age, sex, height and weight, and initial blood pressure, heart rate, respiratory rate, severity of asthmatic attack (percent predicted peak expiratory flow [PEF]), and baseline serum theophylline level of each treatment group. (Predicted PEF was determined from a nomogram provided by the manufacturer of the Wright peak flow meter and varied as a function of patient height and age.) No significant differences were found (P < 0.05) (Table 1). Antecedent drug use, particularly with xanthine-containing bronchodilators was common, as was the use of sympathomimetic inhalers and steroids. Otherwise, our population was remarkably free of pharmaceutical drug use. No subject reported the use of chromolyn sodium or beclomethasone. As noted in our Methods section, patients with initial theophylline levels about 8μg/ml were not considered in our final data analysis, and those who had used a sympathomimetic inhaler within four hours of their emergency department visit were not studied at all.
Five patients randomized to the epinephrine-only group and three in the epinephrine-aminophylline group reported prednisone use in excess of 5 mg daily. Only a single dysrhythmic patient was noted in each group.
All patients treated with aminophylline and epinephrine (n = 20) were shown to have theophylline levels in excess of 8/ig/ml, and those receiving only epinephrine remained near their baseline levels or showed a slight decrease of serum theophylline. This is shown in Figure 1. Only one patient in the epi-nephrine-aminophylline group had a mean serum theophylline level > 20μg/ml.
Cardiac Dysrhythmias During the Treatment of Acute Asthma: A Comparison of Two Treatment Regimens by a Double Blind Protocol with My Canadian Pharmacy
Aminophylline and epinephrine are effective bron-chodilators which are routinely employed in the emergency treatment of asthma. Although subcutaneous epinephrine is frequently used as initial therapy, typically as a series of injections, patients manifesting severe bronchospasm may prompt consideration of combination epinephrine-aminophyl-line when they first come to the emergency department. Cases refractory to initial epinephrine treatment(s) may also receive combination therapy. The dysrhythmogenic potential of these agents, singly or in combination, during the treatment of acute asthma, is unclear.
Patients presenting to the Johns Hopkins Hospital Adult Emergency Department with a chief complaint of asthma, characterized by shortness of breath and wheezing, meeting the criteria for this disorder accepted by the American Thoracic Society, and arriving at a time when our principal investigator (GWJ) was present, were considered for inclusion in the study. Patients were disqualified if they were over 50 years of age, had a history of cardiovascular disease (CVD), manifested cough or significant sputum during symptom-free periods, or had no prior history of asthma or wheezing. Patients with a history of recent use (within four hours) of sympathomimetic bronchodilators, by inhalation, were also excluded. The purpose of the investigation was explained to all eligible patients and willing participants signed written consent.
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