Respiratory physiotherapy for cystic fibrosis

Respiratory physiotherapy for cystic fibrosis

Volume 115 Number 1 Editorial correspondence REFERENCES REFERENCES 1. 2. Ng WG, Xu YK, Kaufman FR, Donnell GN. Uridine nucleotide sugar deficien...

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Volume 115 Number 1

Editorial correspondence





Ng WG, Xu YK, Kaufman FR, Donnell GN. Uridine nucleotide sugar deficiency in galactosemia: implications. Clin Res 1987;35:212A. Roe TF, Hallatt JG, Donnell GN, Ng WG. Childbearing by a galactosemic woman. J PEmATR 1971;78:1026-30.




Hepatic veno-occlusive disease and herbal teas To the Editor: Roulet et al. (J PBOXATR 1988;112:433-6) described a case of fatal hepatic veno-occlusive disease in a newborn infant after consumption by the child's mother of an herbal tea containing pyrrolizidine alkaloids. The article adds to a growing body of literature describing inadvertent toxic effects from herbal products that contain toxic levels of pyrrolizidine alkaloids. Although the pyrrolizidine alkaloids are known to cause hepatic venoocclusive disease, they have also been associated with primary hepatoma, pulmonary endothelial hyperplasia, and glomerular sclerosis? The current case report clarifies the role of transplacental exposure to these toxic compounds. The authors are incorrect, however, in their assertion that their report is the first to present a case of pyrrolizidine poisoning from an "official"* herbal tea rather than a "bush" tea. In fact, several cases of pyrrolizidine alkaloid poisonings have been reported after consumption of commercially available herbal teas. Two of these casesz3 involved consumption of comfrey herb, a widely available herbal tea preparation. The continued commercial availability of comfrey has led Canadian health officials to ban the sale of certain comfrey products in their country. Router et al. are to be applauded for their tenacity in identifying Tussilagofarfara as the plant source of pyrrolizidine poisoning in their report. Inasmuch as there is no method available to measure pyrrolizidine metabolites in body fluids, the diagnosis of pyrrolizidine alkaloid poisoning can be made only by (1) suspecting the diagnosis of veno-oeclusive disease in all cases of hepatic failure, (2) recognizing pathognomonic changes in hepatic tissue obtained on biopsy, and (3) analyzing samples of herbs used by the patient for the presence of pyrrolizidine alkaloids. Unfortunately, physician and consumer awareness of herbal toxicities is extremely limited? It is likely that the incidence of cases of hepatic veno-occlusive disease are therefore grossly underestimated.

Paul M. Ridker, MD Department of Medicine Brigham and Women's Hospital Boston, MA 02115

*The authors intended "official" herbal tea to indicate recognition by pharmaceutical authorities, not just commercial availability.--J.M.G.,




Huxtable RJ. New aspects of the toxicology and pharmacology of pyrrolizidine alkaloids. Gen Pharmacol 1979;10:t5967. Ridker PM, Ohkuma S, McDermott WV, Trey C, Huxtable RJ. Hepatic veno-occlusive disease associated with the consumption of pyrrolizidine containing dietary supplements. Gastroenterology 1985;88:1050-4. Weston CFM, Cooper BT, Davies JD, Levine DF. Venoocclusive disease of the liver secondary to ingestion of comfrey. Br Med J 1987;295:183. Ridker PM. Toxic effects of herbal teas. Arch Environ Health 1987;42:133-6.

Respiratory physiotherapy for cystic fibrosis To the Editor: As two of the early advocates and researchers of the forced expiration technique, 1 we were dismayed to read the article by Reisman et al., "Role of Conventional Physiotherapy in Cystic Fibrosis" (J PEDIATR 1988;113:632-6). The inference is that the "forced expiratory technique" is the forced expiration technique, and as a result some physicians and physiotherapists are correlating the outcome. The technique described as "two maximal inspirations, each followed by a prolonged, controlled, forced expiration, and then three normal quiet inspirations, each followed by a prolonged, controlled, forced expiration" is not the forced expiration technique. The forced expiration technique consists of one or two forced expirations from mid lung volume to low lung volume (to clear the more peripheral secretions) combined with periods of breathing control? When secretions are mobilized to the upper airways, a forced expiration from a high lung volume will lead to expectoration of these secretions. It has never been recommended that the forced expiration technique be undertaken in isolation. It is a part of the active cycle of breathing techniques used in the clearance of excess bronchial secretions. Gravity-assisted positions increase the weight of sputum expectorated when the forced expiration technique is used, ~ but between exacerbations of bronchopulmonary infection, chest clapping may be insignificant.4 We were not surprised that "the forced expiratory technique alone" was associated with mean annual rates of decline in pulmonary function, for used as outlioed, it would have little more effect than no physiotherapy. When the forced expiration technique is used as recommended,2 pulmonary function improves?

Barbara A. Webber, FCSP Group Superintendent Physiotherapist Jennifer A. Pryor, FNZSP, MCSP Deputy Group Superintendent Physiotherapist Physiotherapy Department, Brompton Hospital London SW3 6HP, England


Editorial correspondence


The Journal of Pediatrics July 1989

Therapy for shi.qellosis

1. Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979; 2:417-8. 2. Webber BA. The Brompton Hospital guide to chest physiotherapy. 5th ed. Oxford: Blackwell Scientific, 1988. 3. Sutton PP, Parker RA, Webber BA. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. Eur J Respir Dis 1983; 64:62-8. 4. Webber BA, Parker RA, Hofmeyr JL, Hodson ME. Evaluation of self-percussion during postural drainage using the forced expiration technique. Physiotherapy Practice 1985; 1:42-5. 5. Webber BA, Hofmeyr JL, Morgan MDL, Hodson ME. Effects of postural drainage incorporating the forced expiration technique on pulmonary function in cystic fibrosis. Br J Dis Chest 1986;80:353-9.

Reply To the Editor." w e regret the dismay we have caused Miss Webber and Miss Pryor, and we acknowledge the great pioneering work done in the Brompton Hospital in the field of physiotherapy. However, the purpose of all forms of physiotherapy, including both conventional physiotherapy with percussion and postural drainage and the forced expiration technique, is to help mobilize respiratory tract secretions and facilitate expectoration by stimulating cough. The line in our article after the material quoted in the above letter reads: "A minimum of three coughs was performed, or coughs were performed until there was no more sputum to expectorate." Our series of expiratory maneuvers was described in the Methods section because it does differ from the Brompton technique. Our study was undertaken because conventional chest physiotherapy imposes tremendous time and emotional costs on patients with cystic fibrosis. We were determined to see whether we could find an alternative to percussion and postural drainage. The forced expiration technique described is simple to learn and has been found to be very effective by many of our patients. Nowhere in the article did we state that the Brompton physiotherpists used their forced expiration technique without conventional physiotherapy, but forced expiratory maneuvers are an alternate method that we believe deserve comparison with conventional physiotherapy. The Brompton physiotherapists object to our techniques as described, but there are those who believe that forced prolonged expiratory maneuvers of any kind can lead to airway compression and bronchoconstriction (e.g., Oberwaldner et al., Pediatr Pulmonol 1986;2:358-67. We have strived to simplify our patients' lives by trying to determine whether conventional physiotherapy does lessen the progressive pulmonary decline characteristic of cystic fibrosis. Our long-term study demonstrates a strong suggestion that pulmonary disease progresses more rapidly when percussion and postural drainage are discontinued.

J. J. Reisman, MD H. Levison, MD The Hospital for Sick Children Toronto, Ontario M5G IX8, Canada

To the Editor: Salam and Bennish (J PEDIATR1988; 113:901-7) concluded that nalidixic acid is an effective alternative to ampicillin in the treatment of shigellosis. We want to call attentiofi to the problem of antibiotic resistance. The more antibiotics are used, the more resistance will develop. We have studied drug resistance in Shigella strains prospectively in a rural area near Ankara (S. flexneri, 21 cases; S. sonnei, 8 cases; S. boydii, l case)? Comparison with data from a study in the same region in 19812 shows that the resistance to shigellae has increased:

Agent Sulfamethoxazole-trimethoprim Ampicillin Nalidixic acid

Resistant species (%) 1981 1988 7.5 53 30 43 1 23

We want to emphasize that the antibiotics should be used mainly in severe shigella dysentery (particularly due to S. dysenteriae). We must he careful using antibiotic treatment because of the danger of antibiotic resistance.

L Safa Kaya, MD Mehmet Ceyhan, MD I~gur Dilmen, MD Department of Pediatrics Turkish Health and Therapy Foundation Memorial Ahmet Ors Hospital 06510 Emek Ankara, Turkey Volkan Korten, MD Ali Mert, PhD Department of Internal Medicine and Public Health Laboratory Etimesgut Rural Hospital Ankara, Turkey REFERENCES 1.

Ceyhan M, Dilmen U, Korten V, Mert A. Shigella diarrhoea and treatment. Lancet 1988;2:45-6 Berkman E. The serotypes and antibiotic resistance of shigellae. (~ocuk Sa~l Hast Derg 1983;26:27%86.

Reply, To the Editor: Dr. Kaya and colleagues raise important points concerning which patients with shigellosis should receive antimicrobial therapy, and whether selective treatment of patients with shigellosis would slow the development of resistance to antimierobial agents used for its treatment. Our study, like most studies evaluating treatment of shigellosis, included only patients with shigellosis who had signs and symptoms of dysentery. Our finding that effective antimicrobial therapy leads to a statistically significant and clinically important reduction in the duration of dysentery and fever is consistent with