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com

Thorax 1998;53:813–814 813

(COPD) in an outpatient setting. Thorax complicated by the ability of fibrosis in mixed

1997;52:879–87. emphysematous-fibrotic areas to support the
LETTERS TO 2 Ferrer M, Alonso J, Prieto L, et al. Validity and
reliability of the St George’s Respiratory Ques- airways and mitigate the expected gas trap-
tionnaire after adaptation to a diVerent lan- ping.
THE EDITOR guage and culture: the Spanish example. Eur
Respir J 1996;9:1160–6.
“Emphysematous” changes were seen in
3 Prieto L, Alonso J, Ferrer M, Antó JM for the only six of 21 patients with CFA and
Quality of Life in COPD Study Group. Are preserved lung volumes (only seven of whom
results of the SF-36 health survey and the Not- had HRCT scans). Were expiratory CT scans
tingham Health Profile similar? A comparison
in COPD patients. J Clin Epidemiol 1997;50: performed? We note the normal RV/TLC and
Comparison of outcome 463–73. FEV1/VC ratios. In the absence of functional
measures in patients with data for these spaces, we reserve judgement
about the pathology.
COPD AUTHORS’ REPLY We thank Dr Ferrer and NICOLA STRICKLAND
colleagues for their interest in our paper. We J M B HUGHES
1
Harper et al found completion rates and suc- examined our results in relation to comple- Department of Imaging,
cess scaling rates of the St George’s Respira- tion in two ways; firstly, patients who Hammersmith Hospital,
tory Questionnaire (SGRQ) lower than those completed or did not complete all items of DuCane Road,
observed in other questionnaires completed the Impact dimension and found small and London W12 0HS, UK
by patients with COPD attending an outpa- inconsistent diVerences between them; and,
tient clinic. Readers may infer from this find- secondly, patients who completed all four
ing that the SGRQ is a less useful instrument questionnaires or completed three or less and 1 Doherty MJ, et al. Cryptogenic fibrosing alveoli-
than the Chronic Respiratory Questionnaire found that the only significantly diVerent tis with preserved lung volumes. Thorax
(CRQ), but an alternative explanation may lie 1997;52:998–1002.
patient characteristic was in the distance 2 Strickland N, et al. Am J Roentgenol 1995;161:
on some methodological limitations of the walked. We feel that such diVerences are 719–25.
study. unlikely to explain those observed in general
Firstly, the CRQ was administered only to for completion and consistency for the
an opportunistic subsample and, unfortu- SGRQ. AUTHORS’ REPLY We thank Dr Strickland and
nately, the authors provide insuYcient infor- At the time of our study a method of Professor Hughes for their helpful comments
mation to rule out systematic diVerences with imputing was under development for the on the diVerentiation of emphysema from
the rest of the patients. Secondly, the claim SGRQ. Besides, we have doubts about the large cystic changes in CFA. We have tried to
that SGRQ had lower completion rates may validity of substitution for high rates of miss- stress the limitations of our data in the
reflect the local condition in which it was ing data, nor are we convinced that encourag- discussion section of our paper and have tried
applied rather than a general limitation. The ing patients to complete omitted items to emphasise that emphysema was found on
CRQ was administered by an interviewer produces valid responses. More supervision CT scans in only six of 21 patients with pre-
while the SGRQ was self-administered, and it than was available in our study may have served lung volumes, though this included six
is well established that self-administered increased the level of completion at some of the seven patients who had a comparable
questionnaires are more prone to missing cost, but not necessarily the level of consist- CT scan appearance. We also commented on
items than those interviewer-administered. ency. However, for routine clinical use what the findings of the normal RV/TLC and
Moreover, supervision of completion can we need are questionnaires which do not FEV1/FVC ratios.
reduce missing data substantially. In a study require any supervision, such as a self- The CT criteria used in our paper to diag-
of ours in 321 men with COPD,2 75% of complete version of the CRQ. nose emphysema were rather more specific
patients self-completed the SGRQ and only The low correlation of items with their than indicated in their letter in that they
22% of individuals with missing items were hypothesised dimensions for the SGRQ may
included the presence of areas of low attenu-
observed. Missing information was reduced be indicative of our patient group, which was
ation or bullae (air spaces with a 1 cm diam-
to 0% after the imputation algorithm recom- clearly described as elderly and with long-
standing disease, but in our experience this eter with a wall frequency of less than 1 mm).
mended by the developers of the question-
group is typical of those attending outpatient The former description of unmarginated
naire was applied. It is important to note that
Harper et al did not apply the algorithm of clinics in the UK. areas could not be mistaken for the cystic
imputation in the SGRQ but they did impute We would like to point out that in our con- changes of CFA. The subjects with preserved
the missing items of the CRQ. An appropri- cluding sentence we were careful to express lung volumes did not show more extensive
ate design to allow for comparisons requires, reservations about the instruments of choice. fibrosis which might otherwise have caused
at least, that the same instruments be admin- We suggested further development of the two pathological enlargement of the air spaces.
istered to all the individuals controlling for condition-specific questionnaires and possi- All this supports our view that their changes
the order and type of administration.3 ble additions to the generic SF-36, and would were due to emphysema; neither do we
Finally, the small sample sizes used may certainly like to encourage more specific believe that the eVects of cigarette smoking
have influenced their results in general and, in research into patient perceived quality of life on the airways are necessarily confined to
particular, do not allow the authors to be measures for this significant patient group. pathological alveolar destruction. Co-existing
conclusive about the lower (54%) success ROSEMARY HARPER small airways disease provides an alternative
scaling rate of the SGRQ—that is, the JOHN BRAZIER and plausible explanation of the physiological
proportion of items which correlate >0.4 with School of Health and Related Research, findings we noted in our patients with
their hypothesised dimension. In our study University of SheYeld preserved lung volumes. Clearly, this is
substantially higher success scaling rates were JUDITH WATERHOUSE related to their significant cigarette exposure.
found (78%).2 Department of Medicine and Pharmacology, Neither expiratory CT scans nor V/Q
In conclusion, we believe that the compari- University of SheYeld, scanning were performed in these subjects.
son of the SGRQ with the CRQ and other SheYeld S1 4DA, UK This reflects the retrospective nature of the
instruments by Harper et al is of interest but data, many of the subjects having been inves-
is inconclusive. A more accurate and specific tigated before the publication of the paper by
comparison is therefore still needed.
Strickland and Hughes.
MONTSE FERRER CFA with preserved lung Prospective studies utilising their tech-
JORDI ALONSO nique would be helpful in providing further
LUIS PRIETO volumes
information to support our view that the
JOSEP M ANTÓ
Health Services and Respiratory and Doherty et al1 seem confident of their ability changes seen in patients with CFA with this
Environmental Research Units, to distinguish emphysematous spaces from pattern of physiological abnormality are
Institut Municipal d’Investigació Mèdica, large cystic spaces of honeycomb lung on the indeed due to smoking related obstructive
C/ Doctor Aiguader 80, basis of a wall thickness on HRCT scanning lung disease.
08003 Barcelona, Spain
of greater or less than 1 mm. In cryptogenic M J DOHERTY
fibrosing alveolitis (CFA) we think this is dif- P M A CALVERLEY
1 Harper R, Brazier JE, Waterhouse JC, et al.
ficult unless an assessment of function (with Aintree Chest Clinic,
Comparison of outcome measures for patients V/Q scanning or expiratory CT scans) is Fazakerley Hospital,
with chronic obstructive pulmonary disease made at the same time.2 The situation is Liverpool, UK
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814 Letters, Book reviews

Serum adenosine the numerous examples of lung function the

author comes down firmly on the use of SR to
deaminase activity in BOOK REVIEWS define an abnormal result. As a concession to
pleural eVusion those who do not calculate the SR, the
percentage predicted value is also given. The
format guides the reader from the simplistic
Pleural eVusion is a common complication of Interpretation of Pulmonary Function “within normal limits” to the comprehensive
many disease processes. Tuberculosis is still
Tests: A Practical Guide. Hyatt RE, Scan- report which recommends additional avenues
one of the most important causes of exuda-
lon PD, Nakamura M. (Pp 212; £30.50). of investigation and the consideration of
tive eVusions.1 Over the last decade many
USA: Lippincott-Raven, 1997. ISBN 0 316 likely pathologies. Additional levels of com-
workers have emphasised the importance of
26261 7. plexity are presented one step at a time and
estimating adenosine deaminase (ADA) in
each chapter ends with a useful summary.
pleural fluid.2 ADA activity in human biologi-
It is the authors’ stated aim to produce a con- Test repeatability is dealt with briefly and
cal fluid results from the action of two
cise and practical guide to the interpretation there is a short chapter on serial lung function
isoenzymes—namely, ADA1 and ADA2—with
of pulmonary function tests. As learning to tests. This is perhaps too brief and would
diVerent aYnities on two substrates, 2'
interpret pulmonary function tests often have benefited from a more detailed assess-
deoxyadenosine and adenosine, respectively.
appears daunting to both medical and techni- ment and additional examples including
The deaminase ratio (ADA1/ADA2) is of value
cal trainees, such a book would be a useful some pre and post-treatment changes. The
in the correct diVerentiation of the aetiology
addition to the literature on the subject. The chapter on exercise tests is superficial and
of the disease, whether it is infectious or
sleeve notes say this book is “the only practical perhaps the least helpful. The useful appen-
neoplastic.3
guide to the optimal clinical use of pulmonary dix contains 11 worked examples for the
One hundred patients (84 men) with pleu-
function tests”. I had therefore been expecting reader to test him/herself.
ral eVusions admitted to a chest ward were
a diVerent format from standard texts, but 10 This book is a very accessible introduction
divided into four groups including 41 pa-
of the 15 chapters are still descriptions of the to the interpretation of lung function tests. It
tients with tuberculous pleurisy and 15
various tests and how they change in disease. might easily be used for reference and
patients with malignancy. A significant in-
The last four chapters are of a more practical revision for both measurement practitioners
crease in total ADA was observed in those
nature, describing changes in lung function in and for the reporting clinician.
with tuberculous eVusion compared with
those with benign acellular eVusion (98.52 disease including a useful section on which
(20.41) vs 16.25 (1.35) IU/l, p<0.001; ADA tests are likely to be most helpful in various
ratio <0.28 vs 0.30). In addition, patients clinical settings, although there is no mention Lung Biology in Health and Disease.
with metapneumonic pleurisy had high ADA of AIDS or haematological problems. Chapter Volume 111. Dyspnoea. Mahler Donald A.
activity (100.35 (25.65) IU/l) with an ADA 14 comprises a step by step approach to the (Pp 432; $165.00). New York: Marcel
ratio of 0.55 (0.05), and those with malignant interpretation of pulmonary function tests; Dekker, 1998. ISBN 08247 9814 7.
eVusion had an ADA ratio of 0.57 (0.040) although it gives the correct interpretation to
with total ADA activity of 37.41 (1.64) IU/l. the tests, it covers eight pages of text and fig- The preface states that the aim of this volume
In patients with tuberculous eVusion the test ures and is rather diYcult to use—perhaps the is to focus on the problem of dyspnoea as a
had 90% sensitivity and 87% specificity. data could have been incorporated into a flow symptom (the manifestation of a pathophysi-
We thus observed significantly raised ADA diagram. ological condition) and as an illness (the
values in patients with tuberculous, meta- A practical guide to interpreting pulmo- entire range of a person’s understanding and
pneumonic and malignant eVusions, but the nary function tests that is easy to read and response to breathing diYculty).
ADA ratio was <0.45 in those with tubercu- understand would be very useful; however, Fifteen experts in the field have contrib-
lous eVusions and >0.45 in those with malig- this book illustrates that it is diYcult to uted to the 11 chapters in the book. The first
nant or metapneumonic eVusions. The ADA1 achieve this concisely and still provide an presents a conceptual model that considers
isoenzyme is intracellular in location and is understanding of the physiology involved. dyspnoea as a sensation, symptom and
essential for the diVerentiation of lymphoid The authors suggest that structured ap- illness, and the next chapter explores the lan-
cells, particularly T cells.3 An increase in proaches to the interpretation of pulmonary guage of dyspnoea and the various descrip-
ADA1 can be attributed either to extensive function tests have limitations in describing a tors that patients with diVerent diseases use
cellular necrosis or to increased turnover of “gestalt” approach, looking at the spirometric to describe their experience of breathlessness.
lymphoid cells as occurs in metapneumonic results and using the lung volumes and gas The mechanisms of breathlessness, the diag-
pleurisy and malignancy. ADA2 is found only transfer to categorise the anomaly fully. Such nosis of the cause, together with how to assess
in monocyte macrophages and is released methods are used by most experienced and measure the severity of breathlessness
into biological fluids (pleural, peritoneal, reporters of pulmonary function tests, and and its impact upon the patient are covered in
CSF and serum) when they harbour a this method of looking at the whole picture the chapters that follow. Three further chap-
micro-organism.3 High total ADA activity explains why humans are still better than ters address treatment strategies for relieving
and a deaminase ratio of <0.45 implies an computers at reporting pulmonary function breathlessness. These include those specific
increase in ADA2 and the patient is most tests. to the underlying disease process, a very use-
likely to be infected with an intracellular This is not a bad book and, for anyone ful chapter on coping strategies, physical
organism—for example, tuberculosis. On the wanting an entry level guide to pulmonary modalities such as exercise training and
other hand, high total ADA activity and a function tests, it does make the basic points inspiratory muscle training as well as oxygen
deaminase ratio of >0.45 correlated well with clearly. However, I feel the reader would soon and other medications. The final chapter
malignancy or empyema in the present study. require a more comprehensive text or an evaluates the management of dyspnoea in
Our findings suggest that the deaminase ratio additional volume on physiology. patients receiving ventilatory assistance.
may be a useful screening test in the diagno- Whilst there is some similarity between the
sis of exudative pleural eVusions. chapters contributed by the same authors to
Lung Function Tests: A Guide to their both Mahler’s earlier book on dyspnoea
VEENA SINGH
SIMMI KHARB Interpretation. Kinnear William JM. (Pp (published in 1990 by Futura) and this
P S GHALAUT 162; £19.50 paperback). Nottingham: Not- volume, in each instance the chapters have
ASHOK JANMEJA tingham University Press, 1998. ISBN 1 been expanded to take into account more
22/9J Medical Enclave, 897676 80 8. recent developments. Similarly, whilst some
Pt. B.D. Sharma PGIMS, overlap exists with the recent volume on Res-
Rohtak 124001,
This book adopts a step by step approach to piratory Sensation in this series, this is largely
India
the interpretation of lung function tests. It is complementary rather than repetitive.
aimed at junior doctors specialising in This book is enjoyable to read. It achieves
1 Niwa Y, Kishimoto H, Shimokata K. Carcino- respiratory medicine and clinicians who have its stated aims and represents the most com-
matous and tuberculous pleural eVusions. contact with patients following lung function prehensive and up to date summary of
Comparison of tumour markers. Chest
1985;87:351–5. assessment. The book deals with the most knowledge concerning the management of
2 Banales JL, Pineda PR, Fitzgerald JM. Adenos- commonly performed tests but also includes dyspnoea in this format. It is essential reading
ine deaminase in the diagnosis of tuberculous shorter sections on exercise tests and respira- for professionals involved in research into
pleural eVusions. Chest 1991;99:355–7. tory muscle tests. There is an explanation of dyspnoea and is highly recommended to
3 Gakis C, Naitana A, Ortu AR, et al. Adenosine
deaminase activity in the diagnosis of infectious predicted values, calculation of normal those whose clinical practice largely involves
diseases. Infect Med 1994;11:219–24, 232. ranges and standardised residuals (SR). For caring for breathless patients.
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Interpretation of Pulmonary Function Tests: A

Practical Guide.

Thorax 1998 53: 814

doi: 10.1136/thx.53.9.814

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