Letters to the Editor from studies of Richard Lewis to our patient population. Perhaps an improved and later study could include three parallel groups, one continuing conventional high dose inhaled steroids, one on nebulized and one on M D I high dose Budesonide. The question of relative cost is difficult to address as I have no idea how to cost the consequences of oral steroid therapy. T.W. HIGENBOTTAM
Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, U.K.
529
and to lung function in patients with bronchiectasis. Thorax 1984; 39:408--413. 3. Smallman LA, Hill SL, Stoekley RA. Reduction in ciliary beat frequency in vitro by sputum from patients with bronchiectasis: a serine proteinase effect. Thorax 1984; 39: 663667. 4. Wilson R, Sykes DA, Watson D, Rutman A, Taylor GA, Cole PJ. Measurement of Pseudomonas aeruginosa phenazine pigments in sputum and assessment of their contribution to sputum sol toxicity for respiratory epithelium. Infect Immunol 1988; 56:2515-2517. 5. Munro NC, Barker A, Rutman A e t aL The effect of pyocyanin and l-hydroxyphenazine on in vivo tracheal mucus velocity. JAppl Physio11989; 67: 317-323.
17 June 1992 Reply to letter from Dr Munro Dear Editor The article by Elborn et al. (1) demonstrated a fall in daily sputum production of around 3 g, reduction in cough, and modest improvements in FEV t and P E F R in patients with bronchiectasis treated with inhaled beclomethasone for 6 weeks. Responses to treatment appreciated by patients with bronchiectasis are large changes in volume or the rendering mucoid of previously purulent sputum. It would therefore be of interest to have information on sputum purulence in the patients studied in this series, and in what way, if any, this was changed by inhaled beclomethasone. Purulent sputum contains a number of substances which may damage respiratory epithelium or slow muco-ciliary clearance. Host derived factors present in purulent sputum exhibit proteolytic potential (2) and reduce ciliary beat frequency in vitro (3). Bacterial products identified in infected sputum (4) slow ciliary beating and damage respiratory epithelium in vitro, and slow tracheal mucus velocity in vivo (5). The effect of inhaled steroids on purulence, and the components of purulent sputum, in patients with bronchiectasis may more accurately predict success in preventing bronchial damage. N.C. MUNRO
Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon- Tyne, NE1 4LP, U.K. 13 April 1992
References 1. Elborn JS, Johnston B, Allen F, Clarke J, McGarry J, Vargbese G. Inhaled steroids in patients with bronchiectasis. Respir Med 1992; 86: 121-124. 2. Stockley RA, Hill SL, Morrison HM, Starkice CM. Elastolyticactivity of sputum and its relation to purulence
I thank Dr Munro for this further enquiry regarding our study investigating the effect of inhaled steroids in patients with bronchiectasis. No assessment of sputum purulence was made during the study and so we cannot comment on this issue. The primary end-point we examined was sputum weight which was significantly reduced. It is clear that further studies investigating the role of inhaled corticosteroids in the management of bronchiectasis are required to establish the effects on the inflammatory response. I agree that the effects on inflammatory factors in the sputum may well be more useful in assessing the potential benefit of such therapy. J.S. ELBORN
Section of Respiratory Medicine, Llandough Hospital, Penarth, South Glamorgan CF6 1XX, U.K. 5 June 1992
Dear Editor I would like to report the case o f Stuart K aged 11 years 2 months who was admitted as an emergency to St Mary's Hospital, Newport, I.W. on 9 January 1990 with pain in the upper central chest and front of the base of the neck, and was distressed and sweating. Two days previously he had started with a cold and cough; he had been seen by his doctor the next evening for a sore throat and dyspnoea and had been found to be wheezy, and was prescribed Tabs. Salbutamol 2 rag. He was reviewed on the morning of admission and found to be pyrexial (temperature 37.5°C) with moderate wheeze, hyperinflation due to air trapping and surgical emphysema of the right side of the neck, despite the absence of tracheal shift or other signs of poeumothorax. There was no previous history of
Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, U.K.
529
and to lung function in patients with bronchiectasis. Thorax 1984; 39:408--413. 3. Smallman LA, Hill SL, Stoekley RA. Reduction in ciliary beat frequency in vitro by sputum from patients with bronchiectasis: a serine proteinase effect. Thorax 1984; 39: 663667. 4. Wilson R, Sykes DA, Watson D, Rutman A, Taylor GA, Cole PJ. Measurement of Pseudomonas aeruginosa phenazine pigments in sputum and assessment of their contribution to sputum sol toxicity for respiratory epithelium. Infect Immunol 1988; 56:2515-2517. 5. Munro NC, Barker A, Rutman A e t aL The effect of pyocyanin and l-hydroxyphenazine on in vivo tracheal mucus velocity. JAppl Physio11989; 67: 317-323.
17 June 1992 Reply to letter from Dr Munro Dear Editor The article by Elborn et al. (1) demonstrated a fall in daily sputum production of around 3 g, reduction in cough, and modest improvements in FEV t and P E F R in patients with bronchiectasis treated with inhaled beclomethasone for 6 weeks. Responses to treatment appreciated by patients with bronchiectasis are large changes in volume or the rendering mucoid of previously purulent sputum. It would therefore be of interest to have information on sputum purulence in the patients studied in this series, and in what way, if any, this was changed by inhaled beclomethasone. Purulent sputum contains a number of substances which may damage respiratory epithelium or slow muco-ciliary clearance. Host derived factors present in purulent sputum exhibit proteolytic potential (2) and reduce ciliary beat frequency in vitro (3). Bacterial products identified in infected sputum (4) slow ciliary beating and damage respiratory epithelium in vitro, and slow tracheal mucus velocity in vivo (5). The effect of inhaled steroids on purulence, and the components of purulent sputum, in patients with bronchiectasis may more accurately predict success in preventing bronchial damage. N.C. MUNRO
Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon- Tyne, NE1 4LP, U.K. 13 April 1992
References 1. Elborn JS, Johnston B, Allen F, Clarke J, McGarry J, Vargbese G. Inhaled steroids in patients with bronchiectasis. Respir Med 1992; 86: 121-124. 2. Stockley RA, Hill SL, Morrison HM, Starkice CM. Elastolyticactivity of sputum and its relation to purulence
I thank Dr Munro for this further enquiry regarding our study investigating the effect of inhaled steroids in patients with bronchiectasis. No assessment of sputum purulence was made during the study and so we cannot comment on this issue. The primary end-point we examined was sputum weight which was significantly reduced. It is clear that further studies investigating the role of inhaled corticosteroids in the management of bronchiectasis are required to establish the effects on the inflammatory response. I agree that the effects on inflammatory factors in the sputum may well be more useful in assessing the potential benefit of such therapy. J.S. ELBORN
Section of Respiratory Medicine, Llandough Hospital, Penarth, South Glamorgan CF6 1XX, U.K. 5 June 1992
Dear Editor I would like to report the case o f Stuart K aged 11 years 2 months who was admitted as an emergency to St Mary's Hospital, Newport, I.W. on 9 January 1990 with pain in the upper central chest and front of the base of the neck, and was distressed and sweating. Two days previously he had started with a cold and cough; he had been seen by his doctor the next evening for a sore throat and dyspnoea and had been found to be wheezy, and was prescribed Tabs. Salbutamol 2 rag. He was reviewed on the morning of admission and found to be pyrexial (temperature 37.5°C) with moderate wheeze, hyperinflation due to air trapping and surgical emphysema of the right side of the neck, despite the absence of tracheal shift or other signs of poeumothorax. There was no previous history of
