The Treatment of Pulmonary Emphysema and of Diffuse Pulmonary Fibrosis with Nebulized Bronchodilators and Intermittent Positive Pressure Breathing

Twenty-two patients with chronic pulmonary emphysema were treated for two weeks with oxygen administered by intermittent positive pressure breathing (IPPB) four times daily for 20-minute periods. A bronchodilator was not used. The IPPB treatment without bronchodilators was considered unsatisfactory. Forty-three patients received the combined treatment of isuprel aerosol and oxygen by IPPB at some time during the period they were studied. Twenty patients received the combined treatment without previous regular use of nebulized bronchodilator and 70 per cent reported definite improvement in symptoms, including decreased dyspnea, cough and volume of sputum (when present). Twenty-three patients were treated during an initial period with oxygen and isuprel aerosol without IPPB. Eighteen of these reported symptomatic improvement, an incidence similar to that obtained with the combined bronchodilator and IPPB treatment. The incidence of improvement was similar to that of other reports, in which the combined treatment was used without control studies to determine the separate effects of the features of the combined treatment. Twenty-two of the 23 patients treated with bronchodilators alone then received IPPB in combination with the bronchodilator. Three patients became worse during treatment and two were hospitalized; 15 reported continued improvement. Four of these patients preferred aerosol without IPPB, six preferred the IPPB and bronchodilator combination, feeling that it “opened them up more” and five had no preference. Persistent objective improvement in vital capacity, maximal breathing capacity, nitrogen washout index or arterial oxygen saturation was unusual. Only four of the 42 patients, who at some time during the study received the combined treatment, had persistent improvement in vital capacity and maximal breathing capacity. Three of these patients were 25, 30 and 36 years old respectively and the fourth was 60 years of age. Many patients who had previously used aerosol bronchodilators were found to be using them inefficiently. When they were instructed in the correct use of a nebulizer and when they followed a systematic program similar to that used with IPPB in combination with aerosol bronchodilators, the incidence of symptomatic improvement was similar to that of patients using the combined treatment during short-term treatment. The lack of persistent change in the results obtained by various tests for pulmonary function suggests that none of these therapeutic methods alter the basic pulmonary lesion. The occasional improvement in arterial oxygen saturation, the decrease in cough and volume of sputum and the improved sense of well being suggest an improvement in the bronchial hygiene brought about by the use of aerosol bronchodilators. The only inherent feature of IPPB that we have observed is the assurance of a relatively large tidal volume during aerosol therapy. In alert, ambulatory patients a satisfactory tidal volume can be maintained without mechanical assistance. Five patients with pulmonary fibrosis of uncertain etiology, but with minimal evidence of bronchospasm or other obstructive features, did not improve with use of the combined treatment. Further controlled studies are needed to demonstrate (1) the relative therapeutic effects of long-term bronchodilator treatment with and with-out IPPB, and (2) whether or not the intrapulmonary distribution of gases and aerosols with IPPB differs from that of similar breathing patterns achieved solely by the respiratory muscles.