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difficulty
in
procuring
diagnostic
tissue
may
have
been
related
to the extensive
and severe
squamous
metaplasia
noted throughout
the tracheobronchial
tree of this patient
(Fig 1). Excessive
bleeding
occurred
during
bronchoscopy,
and this was interpreted
as resulting
from
trauma
to some of
these vascular
lesions and to a congested
mucosa.
Patient 2
had extensive
involvement
ofperibronchial
tissue by Kaposi’s
sarcoma,
but the mucosal
involvement
was
only
focal
or
patchy
(Fig
2). This
had normal
also
Kaposi’s
is probably
findings
sarcoma
of
as a possible
paroxysmal
cough
appearance
tracheobronchial
lesions
histologic
made.
Furthermore,
yet hazardous
with
patient
tree
should
be
or recurrent
tumor.
when
the
tree.
The
deposits
of Kaposi’s
we have seen a third
which
involved
the
bronchoscopic
the same as in the two reported
biopsy
was also negative.
At
sarcoma
appearance
cases
and
present
extensively
case 2 (Fig 2). The deep
may be a major reason for the negative
biopsies.
peribronchial
tissue,
these lesions
on bronchial
as in
ACKNOWLEDGEMENT:
Davis for providing
autopsy
was
the bronchial
examination,
post-mortem
were
ing the presence
configuration
on such
loops,
the
“saw-tooth”
sign,
reported
to occur in the syndrome
ofupper
airway
obstruction
and sleep apnea.
This report details the finding
of the same sign in a patient
with Parkinson’s
disease.
CASE
in the
location
of
The authors wish to thank Dr. Joseph
histologic
specimens
on patient 2.
a one-day
history
of productive
cough.
He
had
no
history
of
asthma,
tuberculosis,
or emphysema
and had no history
of hypersomnolence.
He had smoked
one pack ofcigarettes
daily for 30 years
and had discontinued
smoking
ten years previously.
Medications
included
digoxin, alevodopa-carbidopa
combination
(Sinemet),
and
psyllium
hydrophilic
mucilloid
(Metamucil).
Physical
examination
revealed
a thin elderly
man oriented
to
person
only. The pupils
were equal
and reacted
to light and
accommodation.
The tongue was normal in size and midline.
The
uvula was normal,
and no tonsils were seen. The neck was normal,
without
adenopathy
or masses,
and the trachea
was midline.
No
stridorwas
present.
The rightlungwas
dull to percussion
at the base,
and
findings
REPORT
A 70-year-old
man with an 11-year history of Parkinson’s
disease
was admitted
to the hospital because ofconfusion
and disorientation,
with
bleeding.
ADDENDUM
tracheobronchial
of the maximum
inspiratory
and ex1oop is often useful
in demonstratofan upper airway
obstruction.”2
A specific
flow-volume
of the
sarcoma
has already
been
biopsy may be nondiagnostic
Since the completion
of this report,
case of widespread
Kaposi’s
sarcoma
piratory
The
and biopsy
unnecessary
of excessive
he configuration
has been
disseminated
is probably
T
abnormal
biopsy.
is characteristic,
bronchial
because
this
of a persistent
of Kaposi’s
diagnosis
why
tracheobronchial
cause
in patients
bronchoscopic
reason
on bronchial
the
considered
the
A patient
with severe
Parkinson’s
disease
had a maximum
inspiratory
and expiratory
flow-volume
loop showing
a
“saw-tooth”
pattern.
It is concluded
that this sign is not
specific for the sleep apnea syndrome.
rales
were
heard
there
on auscultation.
The
heart
was
regular,
H.
REFERENCES
1
Nadji
M, Morales
AR,
Ziegles-WeissmanJ,
sarcoma:
Immuno-histologic
Arch Pathol
Lab Med 1981;
2
Gottlieb
MS,
Groopman
Penneys
evidence
105:274-75
JE,
Weinstein
WM,
R.
UCLA
conference:
The acquired
drome.
Ann Intern
Med
1983; 99:208-20
3
Friedman-Kien
Klein
sarcoma
4
AE,
E,
Laubenstein
Marmor
M,
in homosexual
Kornfeld
H,
sarcoma
in
Stahl
men.
Axelrod
JL.
a homosexual
U,
R,
al.
origin.
Fahey
JL,
Detels
syn-
P, Buimovici-
Disseminated
Intern
Pulmonary
Med
Am
1982;
Rev
U)
Kaposi’s
96:693-700
presentation
patient.
Kaposi’s
immunodeficiency
Rubinstein
et
Ann
NS.
for an endothelial
of
Respir
Kaposi’s
Dis
1983;
0
127:248-49
5
Misra
DP,
sarcoma
Sunderrajan
of the
EV,
lung:
Hurst
radiography
DJ,
and
Maltby
JD.
pathology.
LL
Kaposi’s
Thorax
1982;
37:155-56
6
Coyas
A, Eliadellis
J
7
E,
Anastassiades
0.
Kaposi’s
Otol 1983; 97:547-49
Gneppe
DR. Chandler
W, Hyams V. Primary
the head and neck. Ann Intern Med 1984;
larynx.
A “SawTooth”
Pattern
Parkinson’s
Disease*
Philip
From
L. Schiffunan,
the
sarcoma
Division
M.D.
,
Kaposi’s
sarcoma
of
100:107-14
in
and
Critical
Care
Medicine,
FIGURE
School,
08903
3
Volume(liters)
F.C.C.Pt
of Pulmonary
2
I
UMDNJ-Rutgers
Medical
School,
New Brunswick,
NJ.
tAssociate
Professor
of Medicine.
Reprint
requests:
Dt Schiffman,
UMDNJ-Rutgers
Medical
Little Albany
Street,
CN 19, New Brunswick,
NewJersey
124
of the
Laryngol
Flow
Note
1. Maximum
inspiratory
above
baseline
is expiratory,
regular
oscillations
in flow
“saw-toothed”
and expiratory
flow-volume
loop.
and below
baseline
is inspiratory.
on inspiratory
limb characteristic
of
pattern.
Saw-tooth
Pattern
in Parkinson
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21447/ on 05/12/2017
Disease
(Philip
L Schiffman)
and the abdomen
at rest,
which
was without
accentuated
“cogwheeling”
ambulation.
and
and
Laboratory
abnormality.
with
studies
stress.
was
noted
revealed
The patient
He
exhibited
to have
a white
had a tremor
severe
a “shuffling
blood
cell
count
gait”
on
of 16,800/cu
mm, with 73 percent
neutrophils,
15 percent
band cells,
6 percent
lymphocytes,
and 6 percent
monocytes.
The hematocrit
reading
was
46.6
percent.
The chest
x-ray
film revealed
right
lower
lobe
pneumonia.
with
left
The electrocardiogram
ventricular
Diagnoses
showed
a normal
sinus
rhythm
Parkinson’s
disease,
and
dementia
the loops
(although
was
ofpoor
inability
continued
vital
quality
due
to the
patient’s
dementia
perform
the test;
an inspiratory
“saw-toothed”
however,
pattern
to adequately
to show
capacity
was
diminished
by 1 L).
DISCUSSION
reported
this time the “saw-toothed”
in relation
to the obstructive
drome.
Sanders
Until
et
al3 first
sign has only
sleep apnea
described
this
sign,
been
syn-
which
is
characterized
as regular
oscillations
in either
the forced
inspiratory
or forced
expiratory
trace of a maximal
flowvolume loop. They found it present
in 11 of 13 patients
with
the sleep apnea syndrome,
reporting
100 percent
specificity,
and attributed
it to the “fluttering”
of upper
airway
tissues.
Haponik
et
a!4 reported
abnormal
flow-volume
ioops
con-
sistent with a variable
extrathoracic
obstruction
in 12 of 27
patients
with sleep apnea syndrome.
They added that a “sawtoothed”
pattern
was present
in some (exact number
not
stated).
Tammelin
et a!5 reported
abnormal
flow-volume
loops in 15 of 22 patients
with
obstructive
sleep
apnea
syndrome,
also reporting
“saw-toothing”
in most. They also
reported
abnormal
syndrome,
one
loops
in three
of whom
did
obese
subjects
demonstrate
without
the
sign and subsequently
did develop
an abnormal
In all of these
studies,
the findings
were
abnormalities
of the
upper
the
“saw-tooth”
sleep study.
attributed
to
rigidity,
and
disease
is clinically
parasympathetic
have
characterized
with
this
disease
described
a pattern
correlated
with
as
ventilatory
primarily
degree
by tremor,
Previous
impairment
Neu
pulmonary
of neurologic
studies
airway
impairment
disease
obstruction
present
(thalamotomy).
et
function
disability,
to be the
in their
Obenour
major
group
feature
in the
shown
in
upper
obese
a linear
progressively
airway
that
may
have
been
patients
fashion,
shorter
time
length
would
units
moving
relatively
regular
pressed
together.
oscillations
become
There are a total ofl3
beginning
end
to the
of inhalation.
be
depicted
as
and
progressively
cornoscillations
from the
to
The
left,
the
exact
duration
of
inhalation
is not measured,
but if it is assumed
to be two to
three seconds,
the oscillation
frequency
is found to be within
the range of the tremor frequency
(three to seven cycles per
of Parkinson’s
disease.9
ADDENDUM
Since
acceptance
upper
airway
with
ofthis
manuscript,
obstruction
Parkinson’s
(Vincken
and
disease
WG,
Cosio
midal
MG.
5G.
Involvement
disorders.
N Engi
Vincken
similar
and
Gauthier
et al have
flow-volume
other
described
loops
in patients
extrapyramidal
Dollfiiss
RE,
disorders.
Hanson
ofupper-airway
RE,
muscles
Darauay
in extrapyra-
J Med 1984;311:438-42).
of the
1 Miller
RD,
Hyatt
RE.
tracheaandlarynx
rigidity,
2 Hyatt
1973;
RE,
of obstructing
Am
lesions
Rev Respir
of the
Dis
1973;
MH,
of sleep
1981;
LE The flow-volume
Martin
apnea
curve.
Am Rev Respir
Rogers
RM.
Dis
in the
RJ, Pennock
awake
BE,
patient:
The
‘saw
The
tooth’
detection
sign.
JAMA
245:2414-18
4 Haponik
5 Tammelin
Black
107:191-99
3 Sanders
disordered
as
Evaluation
by flow-volumeboops.
108:475-81
Abnormal
ventilatory
however,
REFERENCES
a!6
that
et a!8 also found
of patients;
his
with sleep apnea syndrome,5
and since he did not appear
to have the sleep apnea
syndrome,
it must be concluded
that the “saw-tooth”
pattern
is not specific
for the sleep apnea syndrome.
It could
be
argued
that in the absence
of a sleep study,
sleep apnea
has
not been ruled out; however,
he did not manifest
symptoms
ofthe sleep apnea syndrome.
In addition,
the “saw-toothed”
sign in those patients
with the sleep apnea syndrome
is not
considered
to be a result
of the syndrome,
but rather
a
manifestation
ofan anatomic
abnormality
that predisposed
to
this syndrome
which this patient
did not have. One simple
explanation
is that the “saw-tooth”
pattern
was a reflection
of
the patient’s
tremor.
The oscillations
seen in the inspiratory
limb ofthe loop are
relatively
broad
and well separated
at the beginning
of
inhalation
(right) and become
progressively
narrower
and
closer together
toward the end of inhalation
(Fig 1). This is
because
the horizontal
axis represents
volume and does not
depict
time in a linear fashion.
Inhalation
flow rate peaks
quickly
in the loop and then falls progressively.
As volume
is
CM,
and tremor,
and they postulated
increased
parasympathetic
tone as a cause ofthe increased
airway
resistance.
Lilker and
Woolf
confirmed
the ventilatory
abnormalities
found in the
previous
study but saw less correlation
with degree of tremor
and rigidity.
They
found
no significant
improvement
in
pulmonary
function
following
surgical
treatment
of the
Parkinson’s
surrounding
contributory
associated
obstructive.68
of obstructive
the
characterized
hyperactivity.
the
tissue
second)
airway.
The patient described
in this report also had a flow-volume
loop exhibiting
a “saw-toothed”
sign (Fig 1). He was thin and
had neither
symptoms
of the sleep apnea syndrome
nor
reason
to suspect
an anatomic
abnormality
of the upper
airway;
however,
he did have severe
Parkinson’s
disease.
Parkinson’s
cause of the “saw-tooth”
pattern
in the flow-volume
from the patient
presented
in this report
must be
speculative.
He is unlikely
to have had the excess adipose
loop
were
made, and treatment
ofthe pneumonia
was begun. A review
of files
revealed
that studies of pulmonary
function,
including
a maximal
inspiratory
and expiratory
flow-volume
loop, had been performed
14
months
earlier
(Fig 1). The flow-volume
loop was performed
on a 9-L
Collins
dry-seal
spirometer
with
a flow-volume
module
and was
plotted
on an x-y plotter
(Hewlett-Packard
7041A). A “saw-toothed”
pattern was noted on the inspiratorylimb.
A repeat flow-volume
loop
on this admission
and subsequent
pulmonary
disease).
No study has looked
at the configuration
of flow-volume
loops in Parkinson’s
disease
(see addendum).
The
hypertrophy.
ofpneumonia,
symptoms
did not correlate
with pulmonary
dysfunction
and as medical
treatment
of the Parkinson’s
disease (levodopa)
did not improve
the pulmonary
function,
they concluded
that the airway disease in their patients
was
not related to Parkinson’s
disease but rather was a manifestation of a common
coexisting
disease
(chronic
obstructive
neurologic
rigidity
EF,
Bleecker
inspiratory
breathing.
BR,
Wilson
ER,
Allen
flow-volume
Am
Rev
AF,
RP,
curves
Respir
Borowiecki
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21447/ on 05/12/2017
I 87
Dis
Smith
PL, Kaplan
J.
in patients
with sleep1981;
BD,
124:571-74
Sassin
I 1 I JANUARY,
JE
1985
Flow-
125
volume curves reflect pharyngeal
apnea syndrome.
Am Rev Respir
airway abnormalities
in sleep
Dis 1983; 128:712-15
FW, Ladwig
HA, Brody AW
in parkinsonian
patients.
Am
6 Neu HC, connolly
JJ, Schwertley
Obstructive
respiratory
dysfunction
Rev Respir Dis 1967; 95:33-47
7 Lilker
ES, Woolf
CR.
Pulmonary
drome:
the effect of thalamotomy.
function
in
Can
Med
Parkinson’s
Assoc
synJ 1968;
99:752-57
8 Obenour
WH,
Stevens
PM,
Cohen
AA,
causes ofabnormal
pulmonary
function
Rev Respir Dis 1972; 105:382-87
9 Adams
RD,
Victor
McGraw-Hill,
M.
Inc,
Principles
JJ. The
McCutchen
in Parkinson’s
ofneurology,
2nd
disease.
ed.
New
Am
York:
1981:69
Oxygen Cost of Breathing*
Changes Dependent Upon Mode of
Mechanical Ventilation
Richard
Charles
Kanak,
M.D.;
PatrickJ.
Vandenvarf
Fahey,
M.D.
,
F.C.C.P;
and
B.S.
We describe
a patient
with respiratory
failure who demonstrated
marked
increases
in 0, consumption
(Vo5) when
breathing
with synchronized
intermittent
mandatory
mechanical
ventilation
(SIMV).
When
the mode of ventilation
was changed
to facilitate
inspiratory
gas flow (pressuresupport)
during
spontaneous
breathing,
O consumption
decreased
27 percent.
Several
important
factors contributmg to the increased
0, cost of breathing
in patients
requirbig mechanical
ventilation
are reviewed,
including
the high
internal
resistance
of demand-flow
SIMV
systems.
I
n healthy
subjects,
the oxygen
cost ofbreathing,
defined
as
percentage
of total O consumption
used by the muscles
of respiration,
is in the
efficiency
of this system
impaired
pulmonary
frequently
order
of 5 percent
declines,
however,
function
where
the
or less.’
in patients
O cost
The
with
of breathing
is more
than five times normal values.7
Increased
02 consumption
of the
respiratory
muscles
reflects
the
increased
work required
to ventilate
lungs with alterations
in
airway
resistance
and compliance.
In addition,
decreased
strength
and
fatigue
occur
dome
shape
becomes
ated with obstructive
likely
benefits
respiratory
other
the
such
patients
muscles
vital
O
and
tissues.
cost
in the
diaphragm
flattened
due
lung disease.8
by
its normal
associventilation
additional
mechanical
(SvO),
the
O
of
available
ventilation
to
decreases
of ventilation
may be
equally
important.
A patient
we recently
cared for demonstrated marked changes in oxygen consumption,
reflected
by
changes
in continuous
measurement
of mixed venous
O
saturation
of breathing,
#{176}2demands
reducing
making
While
when
to hyperinflation
Mechanical
mode
dependent
on
the
mode
of mechanical
ventilation.
CASE
A 67-year-old
pulmonary
man
disease
with
(COPD),
REPORT
a long
was
history
admitted
increasing
shortness
of breath.
Physical
sided congestive
heart failure and COPD.
diuresis,
and therapy
with supplemental
*From
Loyola
and Respiratory
Reprint requests:
Medical Center,
126
University
Critical
Stntch
School
of chronic
to
the
obstructive
hospital
with
examination
revealed
leftDespite
initial attempts
at
oxygen, and bronchodilaof Medicine,
Care
Section,
Maywood,
Dr Fahey,
Pulmonary
Division,
Maywood,
illinois 60153
Pulmonary
Illinois.
Loyola
University
tors, progressive
respiratory
tion.
Initial
chronized
hypoxemia (Po1 45 mm Hg on 0.5 FIo2 face mask),
distress and hypotension
prompted
endotracheal
intubaventilator
management
(Siemens
900C) included
syn-
intermittent
minute,
tidal
was 273
mI/min.
mandatory
volume
ventilation
(SIMV)
rate
of 8 per
ml, F1o2 0.5,
PEEP
(positive
endexpiratory
pressure)
5 cm H20. On these settings,
arterial blood gas
improved
withlevels
showing Po2, 78 mm Hg; Pco2, 36 mm Hg; and
pH, 7.37. A pulmonary
artery
catheter
(Oximetrix)
providing
continuous
measurement
of SvO revealed
pulmonary
artery pressure 50/28 mm Hg, and pulmonary
capillary wedge pressure
20mm
Hg. Cardiac output by thermodilution
was 3.7 Llmin. Initial Sv02
was 53 percent.
The O consumption
calculated
by the Fick method
700
Figure 1 shows the continuous
measurement
of SvO2 when
the
patient was changed
to pressure
support
ventilation
at + 8 cm H2O.
In this mode, inspiratory
gas flow remains at a continually
positive
pressure,
thereby facilitating
gas delivery and minimizing
resistance
inherent
in the ventilatorand
tubing.
Clinically,
it was noted
that the
patient’s
respiratory
eflbrts
decreased
and
his own
spontaneous
respiratory
rate declined
to 20 breaths
per minute.
A prompt
rise in
Sv02 to 71 percent
followed.
This was not associated
with any
significant
change in arterial
oxygen
levels and cardiac
output
increased only slightly to 4.0 Limin. Calculated
oxygen consumption
decreased
to 199 ml per minute
in the pressure
support
mode.
Spontaneous
breathing
with continuous
positive
airway pressure
(CPAP) at 0 cm H20 again resulted in a prompt
decrease
in Sv02
until return
to pressure
support.
With continued
diuresis
and
bronchodilator
therapy,
the patient was eventually
weaned from the
ventilator
and discharged
from the hospital.
DISCUSSION
While
spontaneously
breathing
in the
SIMV
and
CPAP
this patient
displayed
a 37 percent
increase
in oxygen
consumption,
reflecting
increased
work performed
by respiratory
muscles.
Several
factors
likely contributed
to the
increased
02 requirements
during
spontaneous
ventilation.
Patients
with COPD and hyperinflated
lungs frequently
have
low, flat diaphragms
which are operating
on an inefficient
portion
of their force-length
curve,
and thus a stronger
contraction
and increased
O consumption
are required
for
any given pressure
development.8
Also, some inspiratory
muscles
contract
isometrically,
thus consuming
oxygen,
but
not performing
useful work.’#{176}
In addition,
this patient’s lungs
were edematous
with low compliance
due to pulmonary
edema.
Such lungs require
increased
muscular
work to
ventilate,
further
stressing
the already
inefficient
and fatigued respiratory
muscles.
In the SIMV mode,
the ventilator
delivered
eight breaths
per minute,
while
the patient
continued
to breathe
30
breaths
per minute.
Each of the 22 spontaneous
breaths
mode
required
sure
the
patient
to inspire
with
enough
negative
pres-
valve and inspire
gas through
the
resistance
ofthe
ventilator,
humidifier,
ventilator
tubing, and
endotracheal
tube. Similar demand-flow
systems
have been
shown
to increase
oxygen consumption
by an average
of 16
percent
with a range
of 6 to 46 percent
compared
to
continuous
flow systems
similar to pressure
support
ventilatiOfl.U
Patients
with chronic obstructive
lung disease and the
associated
changes
in respiratory
muscle efficiency
may be
particularly
vulnerable
to the increased
work required
to
breathe
spontaneously
through
demand-flow
gas delivery
systems.
Our patient demonstrated
marked changes
in Sv02
corresponding
with
a 37 percent
increase
in O consumption
during
to open
a demand
spontaneous
ventilation
with
Oxygen Cost of Breathing
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21447/ on 05/12/2017
SIMV
(Kanak,
and
CPAP.
Fahey,
Vandeiwarf