Environmental Air Pollution, Emphysema and Ionized Air

Environmental Air Pollution, Emphysema and Ionized Air* HURLEY

L.

MOTLEY, M.D., F.C.C.P. AND ROMAN YANDA, M.D., F.C.C.P.

Los Angeles, California

M

ANY PATIENTS WITH SEVERE EM-

physema complain of increased breathing difficulties in the Los Angeles area when air pollution is bad. Complaints of a burning sensation in the throat and lungs, soreness of the chest and even chest pain are not uncommon in addition to increased dyspnea. Many of these patients avoid Los Angeles completely when the smog is bad. When hospitalization is required, some require an activated carbon filter in their rooms to remove most of the smog. A physicians' environmental health survey· was conducted in Los Angeles County by random sampling in 1961 by the Los i\ngeles County Medical Association and the Tuberculosis and Health Association of Los Angeles County. One out of every 16 physicians listed in the State Board of California Directory for Los Angeles County received the questionnaire and 53 per cent replied. The survey revealed that 77 per cent of the physicians believed that air pollution affected health adversely. Over 50 per cent of the general practitioners, internists and chest physicians had advised one or more patients to leave Los Angeles County area because of the air pollution. A conservative estimate of the survey indicated over 10,000 people had been advised to leave and that over 2,000 had done so. Nearly one-third of the physicians receiving the survey questionnaire stated they considered leaving the Los Angeles area because of the air pollution. Previous studies employing pulmonary function tests' have revealed that breathing ·From the Cardio-Respiratory Laboratory, University of Southern California and Hospital of the Good Samaritan Medical Center. Presented at Interim Clinical Meeting, American College of Chelt Physicians, Philadelphia, November 28 1965. ' Supported by Grants from U. S. Department Health, Education and Welfare AP-OOl19.

Los Angeles smoggy air by severe emphysema patients aggravates the condition and increases the breathing difficulty. Improvement of the lung volume measurements and intrapulmonary mixing occurred when the emphysema subjects previously exposed to smog were kept in rooms with activated carbon air filtration for two days or more. The activated carbon removes from the air most of the ozone, oxides of nitrogen, sulfur dioxide, unsaturated hydrocarbons and aerosols such as sulfuric acid mists and others. Air conditioning and activated carbon filtration have been used routinely for the intensive care units for several years in some Los Angeles hospitals. The clinical evaluation of the above procedure for sick patients to have pure air to breathe has been most satisfactory. Air conditioners take out part of the smog, but not all. Effects of air pollution in the TokyoYokohama area of Japan have been studied extensively in United States military personnel. I." This illness consists of cough, wheezing (most often at night), dyspnea, prolonged expiratory time (airways obstruction) and minimal secretions. Young men without previous history of respiratory difficulty were affected, as well as some with a past allergic background. The incidence of cigarette smoking was high in the affected group. The bronchitic type of illness appeared to be the combined effects of cigarette smoking and severe air pollution present in the Tokyo-Yokohama area. Removal of the affected individuals from this area in Japan resulted in symptomatic relief. Residence in rooms with activated carbon air filtration at the Camp Zama Army Hospital' was also effective in providing subjective relief and pulmonary function measurements were improved. Follow up studies" have been made on 62 patients sent back to the United States from Japan with 343

344

MOTLEY AND YANDA

diagnosis of Tokyo-Yokohama asthma, and after three years' residence in the United States, 27 continue to cough and wheeze, 30 have abnormal pulmonary function tests, and 26 of the group are worse now than they were in Japan. It appears possible that if the affected individual stays too long in the Tokyo-Yokohama area, emphysema may result. .L\ir pollution from multiple sources appears to cause outbreaks of a~thmatic attacks in New Orleans.' In the group affected, there was an allergic history and a positi"e response to standard allergen skin tests. The incidence of cigarette smoking was low in the New Orleans group, as contrasted to the Tokyo-Yokohama group. In our experience in over 20 years of pulmonary function testing, the presence of severe obstructive pulmonary emphysema is almost invariably associated with heavy cigarette smoking- for many years in patients who give no past history of tuberculosis, asthma, hay fever or occupational exposure to dusts known to produce pneumoconiosis. Cigarette smoking is air pollution .probably at its worst. However, it affects the individual smoker, whereas community air pollution affects all individuals, including the most incapacitated, and the pollution cannot be turned off as with the smoker. The uniformity of air distribution is markedly impaired in severe emphysema,' so that retention of particulates would appear to be increased. Particulates less than one micron in size are high in the Los Angeles area, and air pollutants, as sulfuric acid mists, can be absorbed on to the particulates, which are carried down to the alveolar level and tend to increase retention of the pollutants in the lungs and subsequent irritation. In one patient studied in this laboratory who had severe· pulmonary emphysema and who had smoked three packs of cigarettes a day for many years, it was observed that when smoking, she did not exhale any smoke that could be seen. This indicates that the more severe the emphysema, the more marked the irritating affects from the pollutants such as

Diseases of

the Chest

cigarette smoking. No treatment can be expected to accomplish much in severe emphysema unless cigarette smoking is stopped completely. The U. S. Department of Health, Education and Welfare reports the death rate from emphysema· in men living in the urban areas in California 2.5 times greater than that in men living in rural areas. This would suggest that air pollution from sources other than cigarette smoking was also a probable significant factor. Heavy air pollution in Los Angeles dedecreases the concentration of negative charg~d ions and increases the concentration of the positive charged ions. Many papers have been published on the influence of positive and negative charged air ions. The effect of breathing ionized air on pulmonary function in man is largely unknown. Lefcoe' has reported no significant changes with positive, negative or no ionization on spirometric measurements in 24 patients with mild obstructive pulmonary disease. Windsor and BecketeO report that the body is a collector of atmospheric ions and the positive ions produce mild irritation of the respiratory tract with low humidity, with the patient grounded and with high ion densities. Their conclusions were based primarily on subjective sensations in the patient, rather than a battery of objective measurements of pulmonary function. Kruger and associatesU,lJ report that in mice, rats, guinea pigs, rabbits and monkeys, negative ions enhance the efficiency of the tracheal surface clearing mechanism (accelerate ciliary activity), while positive ions depress. Most of their work has been with the use of extirpated tracheal strips, although some of the observations were made directly through a tracheotomy. They postulate that negative ionized ozygen reacts more rapidly with certain ion porphyrin compounds, which is responsible for increased ciliary beating and rate of mucous flow. They report positive ions make the trachea more vulnerable to trauma. Increased expectoration has occurred in severe emphysema patients from breathing air filtered over activated carbon after

Volume ~Ot No.4 October t 1966

345

AIR POLLUTION, EMPHYSEMA AND IONIZED AIR

being exposed to Los Angeles smog for several days. I Improvement in ciliary action may be responsible. Commercial ion generators are available and widely advertised. Is there any basis for their use in treating chronic pulmonary disease and if so what are the indications? A study was set up to determine by physiologic measurements the nature and extent of changes in pulmonary function measurements which may result from breathing negative and positive air ions at high concentrations. Small negative and positive ions (velocity 1-2 cm./sec.jvoltj cm. ) were measured with the Beckman micro-microammeter and Wesix ion collector. Tubin and RCA ion generators were used. Ion densities of approximately 500,000 ions per ml. were delivered at the level of the nose of the subject. The ion generators were mounted above the patient's face and the ions allowed to drift down like a cloud. The patients were grounded. The method insured adequate ion density at the level of the nose and mouth-. However, as soon as the ion generator was stopped, the ion concentration decreases very rapidly as recorded by the micro-microammeter. How far down the ions go in the lungs is a question. The air in the hospital room was filtered over activated carbon to remove smog. There was no air filtration over activated carbon for patients followed on the long range studies breathing air ions at home. Pulmonary function measurements were obtained before and after the subjects were exposed to breathing the ionized air. The lung valume measurements were obtained from spirogram recordings on the 13.5 liter respirometer, including total vital capacity, the forced expiratory volume for 0.5, 1.0, and 3.0 seconds and the maximal breathing capacity. The Wright peak flow meter was used to obtain maximal peak flow rates. The residual air was measured by the helium closed circuit method previously described. 11 Studies were obtained on 46 subjects with severe emphysema and/or fibrosis aft-

er breathing the negative ions (13 for one hour and 33 for three hours). These studies were made in a room with air filtered over activated carbon to remove smog with a temperature of 70° to 75°F. No significant changes were observed in the lung volume measurements as described above after breathing the negative ions. The data on the ventilation factor are characteristic of the lung volume measurements. The ventilation factor is the average of the forced expiratory volume for three seconds, the maximal breathing capacity and the residual per cent of total lung capacity, all expr~ed on a percentage basis of the predicted norm.al. * The ventilation factor is a single figure value of the ability to use the chest and lungs as a bellows (normal value 100 per cent). In the 33 cases above the average, ventilation factor was 53.9 per cent before and 52.2 per cent after three hours of negative ion breathing (S.D. 4.3 per cent). In only five cases was the difference more than 5 per cent (four decreased and one increased). Subjectively ten of the above 33 cases felt better and one felt worse, while in 22 no change was reported. There was no correlation of the subjective improvement noted above with objective quantitative measurements of pulmonary function (Table 1, Fig. 1). Lung volume measurements were obtained in 19 cases of severe emphysema before and after breathing negative ions at home for two weeks. Also, seven cases of severe emphysema were studied in similar manner at home for lung volume measurements as a control, except the ion generators were not used. The negative ion generators were set the same as used in the ·Ventilation Factor-Calculation ." ~ CJ

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Forced Expiratory Volume for 3 sec. ml. 4260 1657 38.9 Maximal Breathing Capacity, L/min. 126.5 45.2 35.7 Residual % Total Lung Capacity 25.0 58.9 42.4 Ventilation Factor, average of above=39.0%

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MOTLEY AND YANDA

hospital and calibrated to give the high concentration (500,000 ions per ml.) when placed beside the bed or chair approximately two feet above the head. The ion generators were used from seven to 12 hours a day for 14 days. No significant changes were observed in the long exposures. The average ventilation factor for the group was 42.4 per cent before and 41.8 per cent after, with a standard deviation of 5.0 per cent. Only three showed a change greater than 5 per cent (two were decreased and one increased), Fig. 1. In six of the cases, the lung volume studies were repeated after a second two weeks' use at home, making a total of four weeks of breathing negative ions at home, and in these cases there was still no significant difference observed. In one case, measurements were obtained after three hours, two weeks, four weeks, ~nd six weeks.. with no significant differences.

The effect of breathing negative ions on the blood gas exchange was studied in 44 cases of chronic pulmonary disease before and after 30 minutes of breathing negative ions (500,000 ions per ml.). Similar studies were obtained in 35 cases breathing positive ions (500,000 ions per mI.). The arterial blood samples were obtained from the brachial artery using an indwelling Coumand type needle. The arterial content and capacity and carbon dioxide content determinations were made in duplicate and checked by two trained technicians using different manometric Van Slykes. The oxygen capacity was routinely checked by the flask method, in the Van Slyke and from the hemoglobin as measured by the cyanmethemoglobin method by the Beckman DU spectrophotometer. The pH was measured on the Cambridge glass electrode. The arterial pC0 2 was determined by direct tension measurements on the Severinghaus electrode. The arterial

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FIGURE 1: The ventilation factor (V.F.) as per cent of nonnal predicted was plotted on the ordinate before and on the abscissa after breathing negative ions. The V.F. is the average of the forced expiratory volume for 3 seconds, the maximal breathing capacity and the residual per cent of total lung capacity, all expressed on a basis of the predicted nonnal. Data were obtained for the negative ion breathmg on 46 patients with a marked reduction in the V.F. at the start, as follows: 9 after one hour, 22 after three houn and 15 after two weeks. The above data reveal no significant change resulting from the negative ion breathing.

Volume 50, No. 4 October, 1966

347

AIR POLLUTION, EMPHYSEMA AND IONIZED AIR

In so far as possible, each subject served as his or her OWn control and the only difference in the procedure was the type of air breathed. The blood gas exchange studies (Table 2 ) reveal no significant changes in the following measurements: arterial blood saturation, CO 2 content, arterial P02' arterial pC0 2 , pH, minute ventilation, tidal volume, oxygen uptake, oxygen per cent extracted from the inspired air breathed, calculated mean alveolar p02' alveolararterial p02 difference, effective tidal air per cent and carbon monoxide diffusing capacity. There was no difference noted in these studies between breathing the positive and negative ions, as in both cases there was no significant change observed by the tests employed. The group of 35 cases exposed to positive ions had more severe emphysema than the group exposed to negative ions. However, the severity of the hypoxia was about the same in the two groups (Table 2). In contrast, slow deep breathing was studied in 35 of the cases of severe emphysema!1 using an electronic respirator simulator to set the breathing pattern. This device provided the timing pattern of respiration using audible sound resembling

p02 was determined with the Clark electrode. The pulmonary ventilation measurements were obtained from analysis of samples of the expired air collected in a Tissot gasometer. Oxygen uptake and carbon dioxide output were determined from the percentage of oxygen and carbon dioxide in expired air, obtained by Scholander gas analysis. The minute ventilation, the oxygen uptake and the carbon dioxide output were expressed at standard temperature and pressure (STP). The effective tidal air at rest was calculated from the expired pC0 2 and the arterial pC02' The carbon monoxide diffusing capacity measurement was obtained employing the steady state method as described by Filley and associates!· for each pulmonary ventilation study. A rapid infrared LystonBecker analyzer was used for the carbon monoxide determinations. The arterial pC0 2 values obtained with the Severinghaus electrode were used in calculating the carbon monoxide diffusing capacity (CO uptake, mI. per min. per mm. Hg alveolar pCO). Arterial blood and expired air samples were obtained on patients on their own pattern of breathing, and then after 30 minutes of breathing the negative or positive ions the sampling was repeated.

TABLE I-CHANGES IN LUNG VOLUME MEASUREMENTS AND SUBJECTIVE RESPONSES IN EMPHYSEMA PATIENTS BREATHING NEGATIVE IONS As COMPARED WITH CONTROLS

Measurements Vital Capacity FEVo.1 lee. FEVI.olee. FEVLoleC. Maximal Breathing Capacity Intrapulmonary Mixing, Helium Method Maximal Peak Flow Relidual Air Residual Per Cent of Total Lung Capacity Total Lung Capacity Ventilation Factor Subjective Response of the Subject ·Probably Significantly

Comparison Before and After Breathing Negative Ions 3 Houn-33 Cuel Better· Unchanged Worse·

Comparison Before and After Breathing No Negative IODl 3 Houn Relt-8 Cues Better* Unchanged Wone·

5 2 2 1 4

25 28 26 29 20

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27 28 27

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8 8 5

0 0 2

7

23

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6

2

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8

0

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27 28

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22

7

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MOTLEY AND YANDA

nificantly increased in almost all of the cases. There was also a significant increase in the carbon monoxide diffusing capacity measurement with the deeper breathing, and this is in contrast with no changes observed with the negative or positive ions breathing. All of the blood gas studies with the negative and positive ions were conducted in rooms that had activated carbon air filtra-

breathing from a small speaker placed close to the subject's ear. The tidal volume was well controlled on two or more consecutive studies. A 40 to 50 per cent slowing of the respiratory rate and a 50 to 100 per cent increase in tidal volume resulted with the slow breathing. There was a significant improvement in the blood gas exchange for oxygen and carbon dioxide' observed. The arterial blood oxygen saturation was sig-

TABLE 2-8TUDIES ON THE BLOOD GAS EXCHANGE AFTER BREATHING AIR IONS (AVERAGE DATA)

Number of subjects

_

.

Body surface area (BSA) square meten Age in years _ Vital Capacity, mi _ __ _

Per cent of Predicted ._ Timed Vital Capacity for 3 seconds, mi. .. Per cent of Predicted _._ .. _ Maximal Breathing Capacity, L. per min Per cent of Predicted Residual Air, Absolute Volume, mI Per cent of Predicted Residual per cent of Total Lung Capacity Ventilation Factor, per cent Arterial Blood Oxygen Saturation, per cent Carbon Dioxide Content, volumes per cent Arterial pH Pulse rate per minute

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.

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.

Ventilation, liten per min. per sq. M

.

Tidal Air, ml. (Average 3 min. sampling)

.

Carbon Dioxide Output, ml./min./sq.M..-

.

Oxygen Uptake, ml./min./sqM. .

.

Oxygen Per cent Extracted from Inspired Air

.

pOO" Direct Tension Measurement, mm.Hg

.

Alveolar-Arterial po. Difference, mm.Hg

.

Physiological Dead Space, ml.

.

Effective Tidal Air, per cent

.

Carbon Monoxide Diffusion Capacity (ml./min. per mm.Hg alveolar pCO}

. .

*Measurement after breathing negative ions. **Measurement after breathing positive ionl.

30

MINUTES

Negative Ions*

Positive Ions**

44 1.86 52.7 3666 89.6 2722 66.2 79.6 60.6 2532 164.8 39.9 66.5 88.8 * 89.0 48.2 * 48.9 7.44 7.44 * 78 * 77 14.5 * 14.4 3.79 3.67 * 516 * 502 96 * 94 119 * 117 3.23 3.29 * 40.8 * 41.5 17.7 * 18.1 211 * 213 59.1 * 60.9 6.69 6.68 *

35 1.81 59.5 2835 73.0 1661 42.7 37.1 30.9 3364 233.3 54.8 41.0 88.9 ** 88.5 50.4 ** 49.7 7.41 7.41 ** 81 ** 81 14.1 ** 13.7 3.56 3.55 ** 485 ** 505 90 ** 89 115 ** 115 3.30 3.32 ** 42.5 ** 43.1 19.5 ** 18.7 199 ** 216 58.6 ** 56.9 5.94 6.01 **

Volume ~O, No.4 October, 1966

AIR POLLUTION, EMPHYSEMA AND IONIZED AIR

tion, so as to remove as much of the smog present in this area as possible. It was desired to study the possible effects of negative or positive ion breathing in the best possible environment. From the survey of the literature it appears that beneficial effects might be obtained with negative ion breathing in cases with chronic pulmonary disease. To date our work has failed to demonstrate any significant objective changes which can be measured from breathing of negative or positive ions either favorable or unfavorable. The subjective responses on the part of the subject were found to be unreliable. In some cases they stated that the breathing was easier, but the objective measurements revealed no change, and in some cases there was even a slight decrease, which probably was not significant. DISCUSSION

The polluted Los Angeles air has been a problem in the use of the hyperbaric chamber at the Hospital of the Good Samaritan in Los Angeles. The use of air pressures of two to four atmospheres in the chamber was accompanied by a corresponding increase in the concentration of the pollutants,I' and even pollution of oxygen in cylinders was a problem. A 39-year-old policeman assigned to directing traffic in downtown Los Angeles for the past ten years complained that the smog affected his breathing with burning and irritation of the throat. He was a nonsmoker with no history of tuberculosis, asthma, hay fever or exposure to a pneumoconiosis-producing dust. His total vital capacity and maximal breathing capacity were normal. The forced expiratory volume as per cent of the observed vital capacity was as follows: FEVo. 5 , 51 per cent, FEV1.0' 71 per cent and FEV3.0' 95 per cent. The absolute volume of the residual air was 176 per cent of the predicted value for a man of his age and size. The lung volume measurements indicated the absence of a significant degree of emphysema. However, the absolute volume of the residual air was increased in a moderate to

349

marked degree and along with the slight obstructive factor for the rapid forced exhalation may well represent changes present in early emphysema. He should be carefully followed up by serial lung volume measurements, as only follow-up studies over a period of several years will give the final answer. Duty as a traffic officer requires the taking in of a deep breath to blow the whistle each time the traffic light changes, and the deep breath provides an optimal exposure to the air pollution present. This is somewhat similar to the cigarette smoker who inhales. Studies in our laboratory by objective quantitive measurements have revealed a decrease in the arterial blood oxygen saturation after smoking one cigarette by patients with severe emphysema and a decrease in compliance in non-emphysema cases. IT A smoking device was employed so that with each breath some cigarette smoke was inhaled. Emphysema is a parenchymal disease primarily involving the alveoli, which may be associated with or without significant bronchitis. The air spaces distal to the tenninal bronchioles are enlarged due to destruction of the alveolar walls, including obliterating of capillaries and decreasing surface area for gas exchange. The exact cause of emphysema is not known, but irritating factors inducing bronchospasm appear without doubt as materially contributing to the diseased state. Constituents of air pollution are irritating and even particulates alone increase airway resistance.II Breathing polluted air with distension or overstretching of alveoli for prolonged periods of time would appear to favor the development of alveolar changes present iIlt emphysema. Significant bronchitic changes could also be present along with the parenchymal changes. The parenchymal changes in emphysema are not reversible, and the residual air measurement' is one of the best tests of pulmonary function to evaluate progression in the various stages of development. The intrapulmonary mixing test with the nitrogen meter, as evaluated to an end tidal of one per cent, also reveals severe

35°

Diseases of

MOTLEY AND YANDA

impairment in emphysema, but this test is also abnormal in reversible conditions as asthma and allergic bronchitis, although the pattern is usually somewhat different with the latter two as the first part of the pulmonary nitrogen washes out in a more nearly nonnal manner. No significant changes in lung volume measurements were observed in severe emphysema and or fibrosis patients after breathing negative ions (500,000 ions per ml.) in one study of 13 cases for one hour, and in a second study of 33 cases after three hours. No significant differences were observed in lung volume measurements obtained on 19 cases of severe pulmonary emphysema before and after breathing negative ions (500,000 ions per mI.) at home seven to 12 hours a day for two weeks; also the data were no different from that obtained on seven controls studied in a similar fashion except for the ions. Some of the patients reported subjective improvement. However, the subjective sensations were not borne out by changes in the pulmonary function tests employed in this study, as there was no correlation. No significant change in blood gas exchange measurements were observed in 44 cases of severe emphysema and/or fibrosis after breathing negative ions (500,000 ions per mI. ) for 30 minutes. Similar studies revealed no significant change occurred in 35 cases of chronic pulmonary disease after breathing positive ions (500,000 ions per mI.) for 30 minutes (Table 2). SUMMARY

1. The present evidence would indicate that both community air pollution and personal air pollution are important factors in some people developing pulmonary emphysema. We feel that cigarette smoking is the more significant factor at the present time in the development of emphysema as compared to community air pollution. However, this does not mean that community air pollution is not important in the development of emphysema. Previous studies by objective tests have demonstrated that Los Angeles smog aggravates the severity of

the Chest

pulmonary emphysema when present in a marked degree. Longer follow-up studies are needed in more groups to assess better the significance of breathing polluted air for many years. The nonnal large breathing reserve in man and the many variable factors present in the environment render difficult the designing of controlled experiments to demonstrate quickly the significant changes in pulmonary function from community air pollution. 2. It is our feeling at the present time that there is no good evidence to recommend the use of air ions, either negative or positive, in the treatment of chronic pulmonary diseases in man. Although high concentrations of air ions were provided at the level of the nose and mouth, we doubt that there would be many un-neutralized ions that reached the bronchiolar level of the subJect. RESUMEN

1. Las comprobaciones de que disponemos parecen indicar que la contaminaci6n de la atm6sfera ambiental, tanto general como personal, es un factor importante en la producci6n del enfisema pulmonar en algunos individuos. Opinamos que en cigarillo es un factor mas importante actualmente en el desarrollo de dicha afecci6n que la contaminaci6n general del ambiente. Sin embargo, esto no quiere decir que la contaminaci6n del ambiente atmosferico general carezca de importancia. Estudios previos basados en pruebas objetivas han demostrado que la atm6sfera cargada de impurezas de la ciudad de Los Angeles agravan los sintomas del enfisema avanzado. Precisan estudios mas prolongados en diversas colectividades para determinar las consecuencias de respirar aire contaminado de impurezas durante muchos arios. La amplia reserva respiratoria normal en el hombre y los numerosis y variables factores ambientales hacen dincH la practica de experimentos bien controlados encaminados a poner en evidencia a corto plazo los cambios en el funcionalismo pulmonar causados por la contaminaci6n de la atm6sfera general. 2. Nos inclinamos a creer que hasta el presente no existen datos sobre que basar la indicaci6n de iones positivos 0 negativos en el aire en el tratamiento de las afecciones pulmonares cr6nicas en el hombre. Si bien ha sido posible obtener altas concentraciones i6nicas a nive} de nariz y boca, es dudoso que un numero considerable de iones no neutralizados Begue a alcanzar los bronquiolos del paciente.

Volume

~O.

No. 4

October. 1966

AIR POLLUTION, EMPHYSEMA AND IONIZED AIR RESUME

1. Le travail presente par l'auteur a pour but de montrer que la pollution atmospherique d'une collectivite et que la pollution atmospherique sont des facteurs importants de constitution de l'emphyseme chez certains individus. L'auteur estime que la fumee de cigarette est un facteur actuellement plus important que la pollution atmospherique des collectivites comme cause d'apparition d'emphyseme. Toutefois cela ne signifie pas que Ie role de cette pollution des collectivites ne soit pas important. Des etudes anterieures avec des epreuves objectives ont depontre que l'emphyseme pulmonaire, quand il existe deja, est serieusement aggrave a Los Angeles par Ie "smog". Des etudes beaucoup plus longtemps poursuivies dans differents groupements humains sont necessaires pour mieux preciser Ie role que joue une respiration dans l'air polluee durant de nombreuses annees. L'importance du volume respiratoire chez l'homme et les nombreux facteurs variables de l'environment rendent tres difficHes les experiences controlees qui pourraient demontrer rapidement l'action facheuse de la pollution atmospherique collective sur la fonction pulmonaire. 2. L'auteur estime qu'i1 y a actuellement aucun argument valable qui permette de recommander I'action des ions aeriques soit negatifs soit positifs pour traiter la bronchi te chroniq ue chez l'homme. Bien que une forte concentration d'ions aeriques se trouve au niveau du nez et de la bouche, l'auteur ne pense pas que de nombreux ions non neutralises pourraient atteindre la bronchiole. ZUSAMMENFASSUNG

1. Die bisherigen Informationen lassen darauf schliessen, daf,i sowohl die Luftverunreinigung in der Offentlichkeit, die auch im Umkreis der Einzelperson wichtige Faktoren sind bei manchen Menschen, die Entwicklung eines Lungenemphysems betreffen. Wir haben die Oberzeugung, daf,i Zigarettenrauch gegenwartig ein sewenhlicherer Faktor bei der Entwicklung des Emphysems ist im Vergleich zur Luftverunreinigung im oflentlichen Leben. Dies bedeutet jedoch nieht, daf3 eine solehe Luftverunreinigung im offentliehen Leben einer Bedeutung zukommt bei der Entwicklung des Emphysems. Friihere Untersuchungen dureh objektive Teste haben erwiesen, daf3 der "smog" von Los Angeles die Sehwere des Lungenemphysems versdirk, sofem er in einem .ausgepriigten Grad besteht. Untersuchungsreihen, die sieh iiber langere Zeitraume erstreeken und die mehrere Gruppen umfassen, sind erforderlich urn die Signifikanz der verunreinigten Atemluft bei vieljahriger Dauer zu ermitteln. Die normale grof3e Atemreserve des Menschen und die vielen variablen Faktoren, die in seiner Umwelt

35 1

vorliegen, gestalten die Abgrenzung kontrollierter Experimente schwierig, die das Ziel haben, magliehst kurzfristig signifikante Veranderungen in der Lungen funktion durch Luftverunreinigung im offentliehen Leben zu ermitteln. 2. Wir sind der Oberzeugung, daf3 gegenwartig sieh keine eindeutigen Anhaltspunkte dafiir finden, die Anwendung von Lufttionen empfehlenswert erscheinen lassen, seien diese negativ oder positiv zur Behandl ung chronischer Lungenerkrankung des Menschen. Auch wenn hohe Konzentrationen von Luftionen auf der Eingangspforte von Mund und Nase moglieh sind, zweifeln wir daran, daj3 viele nieht neutralisierte Tonen bestehen, die die Bronchiolen der betreflenden Person erreiehen.

2

3

4

5 6

7

8

9

10 11 12

13

14

REFERENCES "Physicians Environment Health Survey," Los Angeles County Medical Association, and Tuberculosis and Health Association of Los Angeles County, May, 1961. MOTLEY, H. L., SMART, R. H. AND LEFTWICH, C. I. : "Effect of Polluted Los Angeles Air (Smog) on Lung Volume Measurements," JAMA, 171: 1469, 1959. PHELPS, H. W. AND KOIKE, S.: "Tokyo-Yokohama Asthma: Rapid Development of Respiratory Distress Presumably Due to Air Pollution," Amer. Rev. Resp. Dis., 86: 55, 1961. PHELPS, H. W.: "Follow-Up Studies in Tokyo Yokohama Respiratory Disease," AMA Arch. Environmental Health, 10: 143, 1965. SPOTNITZ, M.: "The Significance of Yokohama Asthma," Amer. Rev. Resp. Dis., 92:371, 1965. WEILL, H., ZISKIND, M. D., DERBES, V. J., HORTON, R. J. M., MCCALDIN, R. O. AND DICKERSON, R. C.: "Recent Development in New Orleans Asthma," AMA Arch. Environmental Health, 10: 148, 1965. MOTLEY, H. L.: "Physiological Research in Chronic Pulmonary Diseue: An Evaluation of Alveolar Aeration, Oxygen and Carbon Dioxide Transfer and the Pulmonary Circulation," Dis. Chest, 38: 250, 1960. U. S. Dept. of Health, Education and Welfare: "Comparative Mortality Among Metropolitan Areas of the United States, 1949-1951, 102 Causes of Death," U. S. Government Printing Office, Washington, D.C., 1957. LEFCOE, N.: "Ventilatory Function After Exposure to Ionized Air," AMA Arch. Environmental Health, 7: 664, 1963. WINDSOR, T. AND BECKETT, J. F.: "Biological Effects of Ionized Air in Man," Am. /. Physical Med., 37: 83, 1958. KRUEGER, A. P. AND SMITH, R. F.: "Parameten of Gaseous Ion Effects on the Mammalian Trachea," J. Gen. Physiol., 42: 959, 1959. KRUEGER, A. P., SMITH, R. F. AND MILLER, J. W.: "Effects of Air Ions on Trachea of Primates," Proc. Soc. Exper. Bioi. and M ed., 101:506, 1959. MOTLEY, H. L.: "Comparison of a Simple Helium Closed with Oxygen Open Circuit Method for Measuring Residual Air," Amer. R.v. Tuberc., 76:601, 1957. FILLEY, G. F., MAcINTOSH, D. J. AND WRIGHT, G. W.: "Carbon Monoxide Uptake and PulDJonary Diffusing Capacity in Normal Subjects

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at Rest and During Exercise," ]. Clin. Invest., 33: 530, 1954. 15 MOTLEY, H. L.: "The Effects of Slow Deep Breathing on the Blood Gas Exchange in Emphysema," Amer. Rev. Resp. Dis., 88:485, 1963. 16 YANDA, R. L. AND BRYAN, R. J.: "Air Pollution and Hyperbaric Research and Therapy," Hyperbaric Oxygenation, Proceedings of the 2nd International Congress, MeA. Ledingham, Ed. E. S. Livingston, London, 1965.

17 MOTLEY, H. L. AND KUZMAN, W. J.: "Cigarette Smoke. Its Effect on Pulmonary Function Measurements," California M ed., 88: 211, 1958. 18 DUBOIS, A. B. AND DAUTREBANDE, L.: "Acute Effects of Breathing Inert Dust Particles and of Carbachol Aerosol on the Mechanical Characteristics of the Lungs in Man. Changes in Response After Inhaling Sympathomimetic Aerosols," ]. Clin. Invest., 37: 1746, 1958. For reprints, please write Dr. Motley, 1212 Shatto Street, Los Angeles.

INTRATHORACIC SHUNTING OF ESOPHAGUS The authors report a new operative technique-intrathoracic shunting of clcatriclally changed median third of the esophagus with a short pedicled segment of the large intestine. The technique proposed ensures good blood supply of the Intestinal graft and extends Into the function of the nonaffected UJr per and lower regions of the esophagus and cardia. As the result of these changes, there are ellmlnated such compllcatlons as gangrene of the transplant,

retlux-esophagitls, peptic ulcers of the transplant and Its anastomosis with the esophagus, etc. The functional properties of such an artlftcial esophagus are somewhat higher than in other methods of esophagoplasty. PJrraOVSICY. B. V. AND TOSCHAICOV. R. A.: "Intrathoracic Shunting of the Esophagus with a Segment of the Large Intestine in Cicatricial Stricture." Clin. Mea. (USSR). 44:29. 1966.

EFFECTS AND USEFULNESS OF TRIS BUFFER It has been the purpose of thIs discussion to review critically the ph y s I 0 log i c considerations and cllnical evidence regarding the use of Tris buffer (TRAM: trls-hydroxymethyl-amlnomethane) in the treatment of acid-base disorders. It is concluded that there is llttle current evidence, theoretic, experimen-

tal or cllnical, to support the view that this drug has a signiftcant therapeutic role. Some possible exceptions to this general conclusion are considered.

H. L. AND SCHWARTZ, W. B.: "Tris Buffer (THAM): An Appraisal of Its Physiologic Effects and Oinical Usefulness. N,w Bllgl. ]. M,J., 274:782. 1966.

BLEICH,

It

TWO CASES OF BRONCHOGENIC CYST Two cases of mediastinal bronchogenic cyst successfully treated by surgery are reported and the llterature reviewed. Case 1: A 14-year-old boy with no complaint was operated upon and a 7 x 3 em. cyst was removed from the right paratracheal region. This cyst was microscopically revealed as clliated epithellal lining smooth muscle, sero-mucous glands and cartHage.

case 2: A 42-year-old woman with no complaint was operated upon and a nonspeciftc cyst 7 x 7 x 3 em. was removed from the right paratracheal region. Forty-seven cases of mediastinal bronchogenic cyst have been reported In the Japanese llterature.

NAKANO, T. el Ill.: "Two Cases of Bronchogenic Cyst." JIIPanese ]. Thor. SlIr,., 19:63. 1966.